Вы находитесь на странице: 1из 5

Volunteer Application Form

Thank you for your interest in volunteering with


Barts Health. Please complete this form using
block capitals.

Office use only:


DBS Sent
DBS No.
Ref 1 Sent
Ref 2 Sent
OH Form Sent
Training Date

DBS Rcd
Ref 1 Rcd
Ref 2 Rcd
OH Cleared

Please apply strictly to only one Barts Health Hospital. We are one Trust and if you apply to
more than one hospital this creates unnecessary duplication and will delay your application.
Which Hospital would you prefer to volunteer at?

Which role/s are you particularly interested in?

Contact details
Miss
Ms
Mrs
First Name

Last Name

Address
(including
postcode)

Home Tel

Mobile

Email

Date of Birth

Mr

Other (please state)

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

Page 1

No

I dont know

Last updated 19/12/2014

If you currently hold a work permit or visa, please give details including its type and expiry
date:
Have you lived in the UK for the last year?

If you have lived in the UK for less than 1 year 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
Other (please specify)

Friend

Library

GP surgery

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 who have known you for a year or more,
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.
Referee 1
Name
Address
Page 2

Referee 2
Name

Address

Last updated 19/12/2014

Tel

Tel

Email

Email

How does the

referee know you?


(e.g manager)
How long have you
known them?

How does the referee


know you?
(e.g manager)
How long have you
known them?

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
Page 3

Last updated 19/12/2014

information in this form will be held in strictest confidence and in accordance with the Data
Protection Act 1998.
Gender: Male

Female

In which of these categories do you consider yourself to be?


Asian or Asian British

White

Other ethnic groups

British

Indian

Chinese

Irish

Pakistani

Cypriot Greek

Any other White

Bangladeshi

Cypriot Turkish

Any other Asian

Filipino

background
background
Greek

Mixed
White & Black Caribbean

Black or Black British

Somali

White & Black African

Caribbean

Turkish

White and Asian

African

Vietnamese

Any other Mixed

Any other Black

Any other ethnic group

background

background

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
Looking for work
Student full time

Employed part time


Retired
Unable to work

House Husband/Wife
Student part time
Other
(please specify)

Please return the application form and monitoring form to the appropriate contact below:
Sarah Yandell
Jacqueline OSullivan
Volunteer Co-ordinator
Voluntary Services
Barts Health NHS Trust
Barts Health NHS Trust
St Bartholomew's Hospital (Barts)
Newham University Hospital
West Smithfield
Glen Road
London
Plaistow
EC1A 7BE
London E13 8SL
bartsvolunteers@bartshealth.nhs.uk
Jacqueline.OSullivan@bartshealth.nhs.uk

Page 4

Last updated 19/12/2014

Ann Norcott
Volunteer Co-ordinator
The Royal London Hospital
London
E1 1BB
rlhvolunteers@bartshealth.nhs.uk

Page 5

Last updated 19/12/2014