VOLUNTEER APPLICATION FORM
The information contained in this form is intended solely for hospice records and will not be disclosed for any other purpose.
VOLUNTEER WORK I AM INTERESTED IN APPLYING FOR
BIOGRAPHERHOUSE KEEPER
LIVING WELL PROGRAMMEKITCHEN HELPER
DRIVERRECEPTION
FAMILY SUPPORTRETAIL SHOP/WAREHOUSE
FLOWER ARRANGERPAL. CARE ASST
FUNDRAISING EVENTS TRUCK HAND
GARDENER OTHER (specify)
Mr Mrs Miss Ms (please circle)
Surname: ………………………………………...... ……………...……......
First Names: …………………………………………………………………………………….………....…
Address: ………………………………………………………………………………………………...…….
Telephone: Home: ...... Work: ...... Mobile: ......
Email: ...... Occupation: ...... ……………….……..
Emergency Contact (optional but recommended in case of emergency)
Contact Name: ....………………………………………..
Telephone: Home: ...... Work: ...... Mobile: ......
Do you have or have you had an injury, disability or illness which could be further aggravated by any tasks you may be expected to perform? (Please note: This information is required to assist us in meeting our obligations to provide a safe workplace for staff. Declarations of disability or medical condition will not affect your employment opportunity). YES NO
If yes, please describe any technical aids, equipment or adaptations to the workplace that you need in order to safely carry out the full tasks for the position you are applying for.
......
Have you suffered thedeath of a family member or close friend within the previous 12 months?
YES NO
What has attracted you to hospice volunteering? ………………………………………………………..
…………………………………………………………………………………………………………………..
You are expected to attend a one Full Day Te Omanga Hospice orientation course. These are held four times a year. Are you prepared to attend one? YES NO
Are you prepared to attend relevant training courses?YES NO
(Training is compulsory for Biography & Family Support Volunteers)
Do you have any educational background or work experiences you feel will assist you as a hospice volunteer? …………………………………………………………………………………………..
Do you have any previous volunteer experience? (please state) …………………………………..
…………………………………………………………………………………………………………………..
Te Omanga Hospice will use all methods available to protect our patients, their families, our employees, volunteers and the reputation of our organisation from disrepute, and has been accepted as an approved organisation to the vetting service of the New Zealand Police. This allows organisations, whose core function is the provision of care to other people, to check the criminal history of volunteer appointees. Therefore all applicants are requested to sign the attached consent for disclosure form. All information received from the New Zealand Police is stored confidentially on appointment or, on non-appointment, confidentially destroyed.
REFERENCES
Please supply the names of at least TWO referees who you know will be happy to support your application to become a volunteer and their relationship to you. It is preferable that they are people who know you on a personal basis.
Name: ………………………...... ……Phone: ………...... ……..
Relationship to you: …...... …………………......
Name: ………………………...... ……Phone: ………...... ……..
Relationship to you: …...... …………………......
VOLUNTEER CONFIDENTIALITY AGREEMENT
Patients and families involved with the Te Omanga Hospice are accorded confidentiality. As a volunteer with this organisation, I agree to respect and maintain this trust.
I AGREE to my name and phone number being used within the hospice. The personal information contained in this form will be held by and remain confidential to the Volunteer Co-ordinators at Te Omanga Hospice. Under the Privacy Act 1993, I have the right (with certain exceptions) to request access to and correction of, any of my personal information held by the hospice.
I DECLARE that all the information provided by me in support of my application is correct. I acknowledge that if I have provided incorrect or misleading information or have omitted information of significance, I may be disqualified from becoming a volunteer or, if appointed, be liable to be dismissed.
Signed: ………………………………………………………………………Date: ……/……/……
Thank you for volunteering for hospice work. We trust that you will find your endeavours rewarding. Please do not hesitate to contactVolunteer or phone 566 4525 (Option 2) if you have any queries.
FOR OFFICE USE
Reference Check
Comments: ...... …………………………………………………………………….
......
Position: ……………………………………………………………...... Date: ……/……/……
Page 1 of 2Review Date: March 2017
Issued: 06 / Reviewed 2015Authorised By: Janice Henson
Te Omanga Hospice