Volunteer application form final

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Volunteer application form final

  1. 1. Volunteer Application Form Thank you for your interest in volunteering with Barts Health. Please complete this form using block capitals. Which Hospital would you prefer to volunteer at?       Which role/s are you particularly interested in?       Contact details Miss Ms Mrs Mr Other (please state)      First Name       Last Name       Address (including postcode)       Home Tel       Mobile       Email       Date of Birth       Please tick the times and days of the week that would be most convenient for you to volunteer: Mon Tues Wed Thurs Fri Sat Sun Morning Afternoon Early Evening Visa/ Permit Do you need a work permit to work in the United Kingdom? Yes No I don’t know If you currently hold a work permit or visa, please give details including it’s type and expiry date:       Have you lived in the UK for the last 5 years? Page 1 Last updated 01/07/2013
  2. 2.       If you have lived in the UK for less than 5 years do you hold a certificate of good conduct from the other countries you lived in? Yes No If no, are you willing to obtain one? Yes No How did you hear about the position? Trust website Newspaper Friend Library GP surgery Other (please specify)      Relevant Information Why do you want to volunteer for Barts Health and this role in particular?       What skills and experience can you bring to the role? Please include paid and voluntary experience as well as skills that might be useful for the role (e.g. languages, customer service skills). Please continue on to another sheet if necessary.       Is there any other information which you think is relevant to your application?       Emergency Contact Name Telephone Number Relationship to you                   References Please give the names and addresses of two referees, other than relatives or friends, one of whom should be your present or most recent employer/line manager. Students may give the name of a course tutor/lecturer. Long term unemployed applicants may provide the name of a personal referee e.g. neighbour, who has known you for two years or more. Referee 1 Referee 2 Name       Name       Address       Address       Page 2 Last updated 01/07/2013
  3. 3. Tel       Tel       Email       Email       How does the referee know you? (e.g manager)       How does the referee know you? (e.g manager)       Criminal Convictions Posts entailing contact with patients are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974. This means applicants are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act. You should also declare if you have ever received a caution, reprimand or warning. If you are accepted to undertake voluntary work and fail to disclose such convictions, this could result in your dismissal. Please provide information on a separate sheet. Any information given will be completely confidential and will be considered only in relation to any application for voluntary positions to which the order may apply. Do you have any criminal conviction(s)? Yes No (If yes please provide information on a separate sheet) Confidentiality Clause I will under no circumstances divulge or pass on to any unauthorised person or persons; any matters of a confidential nature including information relating to diagnosis and treatment of patients, individual staff records and details of contracts, prices and terms, that I may receive during the course of my voluntary work. I understand that if I breach confidentiality, do not keep to the volunteer role guideline or do not conduct myself in appropriate manner my voluntary work may be terminated. I understand that I will only be eligible for a certificate of attendance and a reference upon completion of 24 session of volunteering. I understand that at any time I may be asked to leave my voluntary placement if my performance is not satisfactory. I understand that this voluntary work does not constitute employment per se and there will not be an entitlement to any form of payment on its cessation. Employment with the Trust is not guaranteed in any way or conferred by this application form. I understand that the voluntary place offered will be subject to the information on this form being correct. Signed:       Date:       Equal Opportunities Monitoring Form Barts Health wants to build a diverse workforce and is committed to a policy of equal opportunities for all. In order to monitor our equal opportunities policy we need to know the proportions of males and females, of different ethnic groups and of people with disabilities within our volunteer programme. This form will form no part of the selection process. The information in this form will be held in strictest confidence and in accordance with the Data Protection Act 1998. Gender: Male Female Page 3 Last updated 01/07/2013
  4. 4. In which of these categories do you consider yourself to be? White Asian or Asian British Other ethnic groups British Indian Chinese Irish Pakistani Cypriot – Greek Any other White background Bangladeshi Cypriot – Turkish Any other Asian background Filipino Mixed Greek White & Black Caribbean Black or Black British Somali White & Black African Caribbean Turkish White and Asian African Vietnamese Any other Mixed background Any other Black background Any other ethnic group Do you consider yourself to have a disability? (The Trust welcomes applications from people with disabilities) Yes No If yes, please let us know what sort of support would enable you to volunteer?       Are you currently? Employed full time Employed part time House Husband/Wife Looking for work Retired Student part time Student full time Unable to work Other (please specify)       Please return the application form and monitoring form to the appropriate contact below: Ann Norcott Volunteer Co-ordinator Barts Health NHS Trust The Royal London Hospital London E1 1BB rlhvolunteers@bartshealth.nhs.uk Jacqueline O’Sullivan Voluntary Services Barts Health NHS Trust Newham University Hospital Glen Road Plaistow London E13 8SL Jacqueline.OSullivan@bartshealth.nhs.uk Page 4 Last updated 01/07/2013
  5. 5. Sarah Yandell Volunteer Co-ordinator Barts Health NHS Trust St Bartholomew's Hospital (Barts) West Smithfield London EC1A 7BE bartsvolunteers@bartshealth.nhs.uk Chandra Vansadia Voluntary Services Lead Barts Health NHS Trust Whipps Cross Hospital Whipps Cross Road Leytonstone E11 1NR chandra.vansadia@bartshealth.nhs.uk Page 5 Last updated 01/07/2013
  6. 6. Sarah Yandell Volunteer Co-ordinator Barts Health NHS Trust St Bartholomew's Hospital (Barts) West Smithfield London EC1A 7BE bartsvolunteers@bartshealth.nhs.uk Chandra Vansadia Voluntary Services Lead Barts Health NHS Trust Whipps Cross Hospital Whipps Cross Road Leytonstone E11 1NR chandra.vansadia@bartshealth.nhs.uk Page 5 Last updated 01/07/2013

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