Volunteer Application Form Personal Details Title (Miss/Mrs/Ms/Mr).. Surname. First Name.. D.O.B Address Postcode.. Telephone number Home... Work Mobile E-Mail. Skills & Interests Education Occupation Hobbies, Interests & Skills Previous Relevant Experience.... Type of voluntary work desired (options will be discussed in detail at interview)..
Availability We ask our Volunteers to commit to a minimum of two hours per week between Monday & Friday Tick as appropriate Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Morning [ ] Afternoon [ ] Are there times during the week you are unavailable to Volunteer?... Have you got access to a car? Yes [ ] No [ ] Sometimes [ ] How did you hear about us? Advertisement [ ] Member of Hospital Staff [ ] Referred by Volunteer [ ] Referred by Friend [ ] YCC Website [ ] Other.. Do you have any physical disability that you think we should know about?.......
1. REHABILITATION OF OFFENDERS ACT (1974) Because of the nature of the Volunteer work for which you are applying, this post is exempt from the provisions of Section (4)2 of the Rehabilitation of Offenders Act (1974). Applicants are therefore NOT ENTITLED to withhold information about convictions which for other purposes are spent under the provisions of the Act and in the event of discovery of any failure to disclose such convictions, The Leeds Teaching Hospitals NHS Trust reserves the right to end any volunteer s placement. Disclosure of an offence will not necessarily be a barrier to becoming a volunteer. All information given below will be considered only in relation to an application for positions to which the order applies. Please disclose details. Offence and Date 2. SCREENING OF VOLUNTEERS APPLYING TO WORK WITH CHILDREN It is the policy of The Leeds Teaching Hospitals NHS Trust to assess the suitability of all volunteers applying to work with children by requesting a police check from the Criminal Records Bureau, the procedure for this will be explained at interview. All information received from the CRB is confidential. I AM / AM NOT happy for my name to be put forward for a police check. (Delete as applicable) If, whilst a volunteer, you are police cautioned, given final warning, are reprimanded or are subject to any police investigation you must inform the Voluntary Services department immediately.
References Please give the names and addresses of two referees who may be contacted. These should be people who have been in a position of responsibility, e.g. your most recent employer or organisations for whom you have worked as a volunteer and preferably known for two years or more and who are able to comment on your suitability to be a volunteer within The Leeds Teaching Hospitals NHS Trust. Close relatives and those under 18 years of age are not acceptable. Referee 1: Name Relationship to applicant Address E-mail... Telephone Referee 2: Name.. Relationship to applicant Address E-mail. Telephone I declare the information on this form is true and complete. I understand that any false information supplied may result in dismissal if appointed as a volunteer:- SIGNATURE.. DATE.
The Trust is an equal opportunities employer. This means that all applications for voluntary work will receive equal treatment irrespective of disability, gender, marital status, race, religion, creed, sexual orientation or colour. To help the Trust monitor its Equal Opportunities Policy please complete the following:- Please tick the box you feel best describes your ethnic origin: British [ ] Irish [ ] White and Black Caribbean [ ] White and Black African [ ] White and Asian [ ] Indian [ ] Pakistani [ ] Bangladeshi [ ] Caribbean [ ] African [ ] Chinese [ ] Other [ ] Not Stated [ ] Not to be retained in Personal File Please return you Application Form to:- Yorkshire Cancer Centre, Fundraising Department, Level 7, St James s Institute of Oncology, Beckett Street, Leeds, LS9 7TF Thank you