Your Work & Life Experience

Thank you for taking the time to consider a volunteer role with Nelson Tasman Hospice. We are incredibly proud of the very real difference our 400+ existing volunteer army makes in our Nelson Tasman community. We are eternally grateful for the gift of volunteer time, energy and skills that allow us to help hospice patients and their families make the most of every day.

In order to fully consider your application we need to find out some information about you. Our goal is to keep you safe during your time with us, and to help you find a volunteer role that you will enjoy and find fulfilling. We only collect information about you that we genuinely need and it is treated in strictest confidence.

Once we have received this we will contact you to arrange an interview and any questions you have can be answered then. Please note – Nelson Tasman Hospice conducts a vetting check on all volunteer applicants aged 17 years and over. For this we need proof of identity. When we arrange your interview we will ask you to bring your identity documents with you.

Your Personal Details

First Name
Surname
Preferred Name (if not First Name)
Street Address
Postal Address (if different from above)
Home Telephone Number
Work Telephone Number
Cellphone Number
Email Address
How would you like to receive most written information e.g. volunteer newsletters? / Via email
Via mail to my postal address
Date of Birth
Ethnicity
Emergency Contact in case of Illness or Emergency (please provide their name, address and telephone number - this does not necessarily need to be a relative)

Your Work & Life Experience

What appeals to you about becoming a volunteer with Nelson Tasman Hospice?
Please tell us your present or previous occupation(s)
Please tell us about any past volunteer work you’ve been involved in
Please tell us about any current volunteer work you are involved in
Do you have any other educational or work experiences you feel would assist you as a volunteer?

Shop based roles

If you are planning on joining us in a volunteer role that involves working at a hospice shop please complete the section below and then continue to referee section on bottom of page 3.

The days and times you are potentially available are:
Shifts are generally 2-4 hours and will be discussed with appropriate Store Manager
Mondays: / Tuesdays: / Wednesdays: / Thursdays: / Fridays: / Saturdays:
Hours: / Hours: / Hours: / Hours: / Hours: / Hours:

Patient Based Roles

Volunteer roles that involve working with patients please complete the section below. If your intended role is non-patient based, just skip this page and continue to the reference check

Have you had any counselling training or experience? Please tell us about it here.
Have you had any nursing or other medical training / experience? Please tell us about it here.
Have you suffered a major loss in your life e.g. bereavement, divorce, illness, redundancy? Please share some information about it here.
Religion and/or spirituality including strong life philosophies can be very important to patients. Volunteers are not encouraged to discuss their private beliefs. How do you feel about this?

Reference Checks

Please provide details of two referees below, the second being a backup if needed.

Referee Name / Referee Contact Details / Their Relationship to You
Phone:
Email:
Phone:
Email:

Your Practical Skills

Many of our volunteer services have come about as a result of someone offering us their specific and sometimes unique skills – both patient and non patient based. Furthermore, it is surprising how often our nurses contact the volunteer office asking if we have volunteers with a specific skill. Sometimes these requests can be quite random in line with interests/needs of our patients. We are keen therefore, to hear about your current skills and interests. Please place a tick against each skill you are able to offer in the boxes below – and please tell us about any others not listed in the blank section at the end (don’t be shy!).

Business & Office

Skill / I can do this!
Accounts / Finance
Administration
Audit
Communications
Database Use
Database Management
Editing / Proof Reader
Events Management
Fundraising
Health & Safety
IT (please specify)
Law
Management
Marketing
MS Excel
MS Outlook
MS Word
MS Powerpoint
Policy Development
Project Management
Public Speaking
Sponsorship
Strategic Planning
Training
Typing
Writing

Beauty & Pampering

Skill / I can do this!
Aromatherapy
Beautician
Hairdressing
Manicurist
Massage

Art & Creativity

Skill / I can do this!
Card Making
Dance
Drama
Drawing
Painting
Jewelry Making
Knitting
Musical Instrument (please specify)
Photography
Sewing
Singing
Furniture

Languages

Skill / I can do this!
Please specify:

Healthcare

Skill / I can do this!
Caregiver
Community Worker
Counselling
Dementia Care
Diversional Therapy
Doctor
First Aid
Meditation
Nursing
Occupational Therapy
Physiotherapy
Social Work

Hobbies

Skill / I can do this!
Baking
Boating
Card Playing
Cooking
Fishing
Flower Arranging
Gardening
Wine
Yoga
Fashion/Clothing

Trades Skills

Skill / I can do this!
Building
Carpentry
Construction
Electrician
Mechanic
Painter
Plumber

Skills or Interests not listed above? Please tell us about them here!

Our Shared Health & Safety Obligations

The Health and Safety in Employment Act aims to promote the health and safety of everyone in and around places of work, including volunteers - please read the information below carefully.

Hospice has a responsibility to:

Ensure that as far as is reasonably practicable, the H&S of volunteers is not put at risk from the work they will be carrying out for Hospice. This includes safe systems of work and everything needed to carry out that work.
Provide information, training, instruction or supervision.
Take reasonable care that volunteers' acts or omissions do not adversely affect the health and safety of other persons i.e. patients, their families and staff.

Volunteers have a responsibility to:

Take reasonable care for their own health and safety.
Take reasonable care their actions or inactions to not adversely affect the health and safety of other persons.
Comply as far as the volunteer is reasonably able, with any reasonable instruction that is given by hospice.
Cooperate with any reasonable policy or procedure of Hospice relating to H&S as outlined in the volunteer's Role Description or other requirements of their role.
Report any/ potential hazards, risks or incidents that they become aware of.

Privacy Act:

A volunteer should not discuss any case, conversation or situation unless the information is publicly available and disclosure is authorised by the person concerned.

Complying means more than simply leaving out names. In a small place like Nelson, even discussing the circumstances surrounding a case, conversation, situation or individual could easily lead to that individual/s being identified. Volunteers who have concerns about a patient or a situation should contact either the Manager, Volunteer Services or another employee of Nelson Tasman hospice.

Your Health & Welfare

This information will not necessarily exclude you from volunteering but knowing your medical history and any current conditions helps us keep you safe. Please be honest and rest assured that any information you provide is treated in confidence. Nothing gets shared, even amongst hospice staff, without your permission.

Yes / No
Are you allergic to, or have sensitivity to any food, substances or chemicals?
Have you ever suffered any back injury, back strain or overuse injury
Have you ever suffered from any of the following: Heart complaint
Blackouts or fits/seizures
Asthma
Eyesight defect which is not corrected by wearing glasses
Mental Health condition which requires ongoing clinical management
If you have answered YES to any of the above Health & Welfare questions, please provide brief details below in order that we can best look after you.
Do you have any other condition that may affect your ability to effectively carry out the functions and responsibilities of a volunteer role? If so, please provide brief details here:

Driving Hospice or Personal Vehicles as a Volunteer(only complete if applicable to role you’re interested in)

Some hospice volunteer roles involve driving a vehicle to transport patients or with the collection and delivery of furniture/equipment. Only complete if the role you’re interested in involves this.

Your Driver Licence Details

Name as it Appears on Your Driver Licence
Driver Licence Number
Driver Licence Expiry Date

Your Personal Vehicle Details

Car Registration Number
Car Make
Car Model
How many doors does the car have? / 2 doors 4 doors
Are there any special features that may impact your ability to transport a patient comfortably? e.g. 4 wheel drive, low sports car
Would you be happy to transport a wheelchair in your car, and able to lift it in and out?

Personal & Vehicle Fitness Requirements as Per Health & Safety Legislation

Please be honest and rest assured that any information you provide is treated in confidence. Nothing gets shared, even amongst hospice staff, without your permission.

Yes / No
I am in good physical health
I have no eyesight defects
I will not transport children without an appropriate to age child restraint
I will inform the Volunteer Manager should I be required to take any medication which could impair my coordination, alertness or judgement as a driver
I have no criminal record relating to driving offences
I have no alcohol or drug problems
I will not drive under the influence of alcohol of any amount
I hold a current NZ light motor vehicle Driver’s Licence
I agree to adhere to the NZ Road Code
I will maintain my vehicle in a clean and roadworthy condition serviced in accordance with the manufacturer’s recommendations by competent persons
I confirm that my vehicle is insured
I confirm that my vehicle is registered and warranted
I am prepared to attend occasional in-service training

Your Declaration

Please check the relevant answer to each question below, then sign to confirm your responses.

Yes No
I have read and understood the shared Health & Safety obligations outlined in this Application Form.
I understand that if I take on a volunteer role with Nelson Tasman Hospice I will be given a Role Description that will contain Health & Safety information relevant to my role that I am expected to comply with.
I understand that the following Acts (around which Health & Safety standards are based), are available to view at the Hospice office: PRIVACY ACT 1993, the HEALTH AND SAFETY IN EMPLOYMENT ACT 2003 and the HEALTH INFORMATION CODE 1994 along with the Nelson Tasman Hospice manuals.
I can safely transport hospice patients and/or their family members if required as part of my volunteer role and I will inform the Manager, Volunteer Services, should anything alter my ability to continue as a volunteer driver. For example: my health, the roadworthiness of my vehicle, a change in my driver licence status.
I am willing to undergo a Police Check via NZ Police should my volunteer role demand it, and agree to provide the required ID for this to take place – primary (e.g. passport, birth certificate) and secondary (e.g. driver’s licence).
Within the past 10 years have you been convicted of any offence (apart from minor traffic convictions) against the law, in New Zealand or overseas. If yes please provide details here:
Do you have any criminal or major traffic charges pending? If yes please provide details here:
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, liable to be dismissed.
Name
Signature
Date of Signing

All new volunteers will be interviewed by a member of the Volunteer services. Placement is based on volunteers skills, experience, interested and availability. However, it may not always be possible to place a volunteer in a particular area of volunteering immediately and whenever possible appropriate alternative roles may be offered.

Thank you for taking the time to complete this form.