Application for Volunteer Positions

Application for Volunteer Positions
About You
Title
First Name
Surname
Address
Post Code
Date Of Birth
Home Tel No (req'd)
Mobile Tel No (req'd)
Email Address
Emergency Contact Information
Name
Relationship
Home Tel No (reqd)
Mobile Tel No (reqd)
Additional Needs
Do you require any additional support because of a Disability? (please circle)
Yes
No
If yes, please state the type of
support you require
Special Qualifications and Skills
Please give any details of any qualifications or special skills that you think may be
beneficial to you in your role as Volunteer at Apple FM (if applicable – if not, leave empty)
Availability
Please indicate your possible times available to help Apple FM (this can be amended)
Days Available
Monday
Tuesday
Wednesday
Thursday
AM
PM
Extra Information
How did you first hear about Apple FM?
1
Friday
Saturday
Sunday
References
Please provide the details of two people who would be willing to supply a character reference (can be your
current or recent employer or someone – but NOT family member)
Reference One
Reference Two
Name
Name
Address
Address
Postcode
Postcode
Capacity known
to you
Capacity known
to you
Email address
Email address
Telephone No
Telephone No
Declaration
To the best of my knowledge the details on this application form are true. I understand that any
misrepresentation found in this application after my appointment may lead to the termination of the
agreement. I understand that the information given by me on this application form will be processed in
accordance with the Data Protection Act 1998.
I understand that this post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as
such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service
(DBS) to check for any previous convictions.
I authorise Apple FM's HR Director (or persons acting on their behalf) to act as intermediary between MPH
HR Dept and myself in relation to my Volunteer application and the DBS & Reference collecting process. I
also give my authorisation that Apple FM's HR Dept should be issued with copies of the replies that are
received in response to reference requests.
Signed
Date
When completed please send to:
Alan Collins, HR Director, Apple FM, The Studio, Musgrove Park, Taunton. TA1 5DA
For Office Use Only
DBS Form Ref
F01
Car Park Pass Required?
Vol Conf Stat Signed
Yes
No
ID Accepted: 1)
If “Yes”, Car Reg No?
2)
Photo Taken
Passed to Vol Serv
Polo Shirt Size
Date Issued
Vol Agmnt Signed
Interview Date
3)
Refs Received 1)
Badge ID No
Trainer
Date Training Started
2
2)
VOLUNTEER CONFIDENTIALITY STATEMENT
Any matters of a confidential nature, including any particular information relating to the diagnosis and
treatment of patients or individual staff records must under no circumstances be divulged or made available
to any unauthorised person(s).
It is important to service users to feel confident that information they give will not be passed on to anyone
without their permission. It is equally important for service users to feel confident in giving us this
information so we can deliver the best possible service.
We ask all volunteers to sign a copy of the statement below to show they understand the need for
confidentiality and agree to keep information confidential.
•
•
•
•
I will respect the privacy of services users, other volunteers and staff and confer appropriately with
those designated as my supervisors.
I will use all information gained in the course of my service in a reasonable manner.
I will not at any time use any photographic equipment on Musgrove Park Hospital premises, unless
authorised to do so.
I understand that misusing information will lead to the suspension or dismissal of my voluntary role.
Name
Signature
Date
3