Volunteer Application Form

VOLUNTEER APPLICATION FORM

Before completing please see the Role Description for the position you are applying for. This can be accessed at www.stbarnabashospice.co.uk or a paper copy can be requested from 01522 518221.

Title First Name Known As Name Last Name

Address Tel No Mobile No Email

Date of Birth

Volunteering role you are applying for and the site

Please tell us about any voluntary or paid experience you have related to the above role and why you would like to volunteer with us

Please tell us about your Please tell us about any previous interests/skills/hobbies experience you have of the hospice

Car Driver? YES / NO Car Available? YES / NO (please delete as (please delete as appropriate) appropriate) Page 1 of 6 How did you hear about our On which days of the week are you volunteering opportunities? available to volunteer for us?

Parent / Guardian Consent Declaration This is required for ALL Volunteers under the age of 18 only. I give my consent for the person named on this application form to volunteer with St.Barnabas Hospice.

Signed………………………………………..Print……………………………………….

Relationship………………………………….Date……………………………………….

EMERGENCY CONTACTS Please give contact details for your next of kin and the person we should contact in case of an emergency. Next of Kin Local Emergency Contact (if different) Name Name Relationship Relationship Address Address

Home Tel No Home Tel No Mobile Tel No Mobile Tel No

REFERENCES Please give details of two people who will provide a reference for you. These people must have known you for at least two years. Examples of referees are a colleague, employer, teacher, friend or neighbour. We cannot accept references from relatives or partners. Please include email addresses where possible – This will speed up the process! Title (Mr, Title (Mr, Mrs etc) Mrs etc) Name Name Address Address

Postcode Postcode Tel No. Tel No. Email Email address address

of 6 St Barnabas Lincolnshire Hospice Volunteer Health Questionnaire

We wish to ensure that any volunteer role offered will not put your health or well being, or the safety of our patients, customers, staff and other volunteers at risk. It is important that you declare health issues that may affect your ability to fulfil the key duties of the volunteer role you have applied for. Where reasonable adaptations can be made to make volunteering possible these will be considered.

Date of Birth

Volunteer role applied for

Please consider the role you are applying for when answering the following questions. Role descriptions which set out the reasonable expectations for each volunteer role can be found at www.stbarnabashospice.co.uk or for a paper copy contact People Development & Support Services on 01522 518221.

Please answer by placing an X in the yes or no box. If you answer yes, please complete the box below. We may ask for some more information to help us make sure that the role you have applied for will be suitable.

Yes No 1. Are you aware of any health conditions which might make it difficult for you to fulfil the key duties of the volunteer role you are applying for?

2. Do you consider that you would require adaptations to your volunteering environment or routines as a result of a current health condition or disability?

If you have answered yes to either of these questions please provide more details.

of 6 REHABILITATION OF OFFENDERS ACT, 1974

Those applying for a volunteer role which is defined by the Disclosure and Barring Service as regulated activity will be exempt from the provision of section 4 (2) of the Rehabilitation of Offenders Act, 1974 (Exemption) Order 1975.

These applicants are, therefore, NOT ENTITLED TO WITHHOLD INFORMATION about convictions which for other purposes are “spent” under the provisions of the Act.

I declare the following convictions: ……………………………………………………………………………………………………………

…….………………………………………………………………………………………………………

□ I do not have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI2013 1198.

Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position applied for and the circumstances and background of your offences. Our full policy statement on the recruitment of ex-offenders available on request.

DECLARATION

I understand the details in this application and will be kept on file which I may have access to at any time. I have no objection to these records being kept on file.

I understand that anything I hear or learn concerning individuals, patients or my work in the course of my duty as a volunteer, must be treated in the strictest confidence.

I acknowledge an appointment, if offered, will be subject to satisfactory medical clearance, references and police clearance where applicable.

I declare the information given on this form is correct and understand that, if appointed, any misleading statements or deliberate omissions may result in the termination of the position offered.

Should you be successful in obtaining this post certain information given on this form will be used to provide your computerised personal record and under the terms of the DATA PROTECTION ACT 1984 will be held securely and treated as being in confidence.

Please sign below if you agree to the above statements:

Signature______Date ______

Full Name ______

of 6 St Barnabas Lincolnshire Hospice Diversity Monitoring Form

At St Barnabas Hospice we aim to eliminate direct or indirect discrimination on grounds, as covered by the Equality Act 2010, of sex, sexual orientation, marital status, colour, race, nationality, ethnic or national origin, creed, religious belief, age or disability.

Please could you take a few moments to complete this form.

GENDER Male Female

AGE Under 25 25 - 34 35 - 44 GROUP 45 - 54 55 - 64 65 or over

DISABILITY According to the Equality Act 2010 a person has a disability if they have a physical or mental impairment and the impairment has a substantial and long-term adverse effect on their ability to perform normal day-to-day activities. Do you consider that you have a disability? Yes No

Do you have any special requirements eg, Yes No wheelchair access?

ETHNICITY Asian or Asian British Black or Black British Bangladeshi African Indian Caribbean Pakistani Any other black background Any other Asian background

Mixed White White and Asian British White and Black African Irish White and Black Caribbean Any other white background Any other mixed background

Other Ethnic Group Chinese Any other ethnic group

RELIGION OR BELIEF How would you describe your religion? Buddhist Christian Hindu Jewish Muslim Sikh Other None

of 6 Thank you for completing this application. Please hand it in to your local St Barnabas Shop in a sealed envelope or post to:

St Barnabas Hospice People Development Team Hawthorn Road Lincoln LN2 4QX

If posting, please ensure that the correct postage is paid, particularly if using a large letter envelope.