ARTHUR RANK HOUSE HOSPICE

Voluntary Services Department,

Brookfields Hospital, 351 Mill Road, Cambridge, CB1 3DF
Main Tel: (01223) 723110 Fax: (01223) 723111
Voluntary Services Tel: (01223) 723145/6
Email: anna-louise.crofts@cambridgeshirepct.nhs.uk Website: www.arthurrankhouse.nhs.uk
CONFIDENTIAL
APPLICATION FORM FOR VOLUNTEERS
Personal Details:
Address: ………………………………………
Title: Mr / Mrs / Miss / Ms / Other………...
…………………………………….……………..
Surname: ……………………………………….
…………………………………….……………..
Forenames: ……………………………………….
Postcode: ……………………………………..
………………………………………
Tel home: …………………………………….….
Age: up to 18 / 18 – 64 / 65 and over
(this information is required in order to Mobile: ………………………………………...
comply with Health & Safety regulations)
Work: ………………………………………..

Email: ……………………………………….

Contact in case of accident or emergency:

Name: …………………………………….………… Tel: ………………………………………………

Employment/Educational Status:

Are you currently in full-time education? YES / NO

If yes, please state school/college/etc.: ……………………………………………….

Are you currently employed? YES / NO

If yes: Full-Time / Part-Time

Your current job title: …………………………………………………...

If retired, please give your previous job title: …………………………………………………...

Experience:

Have you ever worked with:

(i) Children …………………………………………………………………………………………
(ii) Elderly care patients …………………………………………………………………………….
Experience continued:

(i) People suffering from mental illness.……………………………………………….……………….

….
(iv) People with a learning/physical disability……………………………………………………………….

Do you have any other skills, training or experience?

Previous voluntary work: Hobbies and interests:

Please give details of any previous experience of

working as a volunteer:

Can you speak any foreign languages? If so,

which?

Transport: Health:

Do you hold a current UK driving licence? YES / NO Are you currently in good health? YES / NO

Do you have your own car? YES / NO Are you registered disabled? YES / NO

Would you be prepared to use your car to transport Do you have special requirements to enable you
patients/visitors/equipment as part of your voluntary to carry out voluntary work?
work?
YES / NO / POSSIBLY ……………………………………………………

……………………………………………………
Candidates who declare a disability or health
problem will be given equal consideration.
Medical Examination:

It may be necessary for you to undergo a medical examination prior to commencing your volunteering.
Are you in agreement with this?
YES / NO

Volunteering at Arthur Rank House:

How did you hear about volunteering at Arthur Rank House?

Please state why you are interested in becoming a hospice volunteer:

From the information leaflet, have you identified any particular tasks/placement areas, for which you
would like to be considered?

Are there any particular tasks/placements for which you would NOT wish to be considered?

Bereavement:

Have you suffered any bereavement?

Availability:

Which days/times are you regularly available?

Morning …………………………………………. Afternoon …………………………………………..

Evening ………………………………………….. Weekend …………………………………………...

References:

Please give the name and contact information of two people, not relatives, who have agreed to act as
referees for you and have known you at least 3 years: (PLEASE USE BLOCK CAPITALS)

Name: (1) ………………………………………….. (2)………………………………………………

Address: ……………………………………………. …………………………………………………

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

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

Post Code: ……………………………………………. …………………………………………………

Tel No: ..………………………………………….. …………………………………………………

PLEASE SIGN EACH OF THE FOLLOWING STATEMENTS:

REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975

Because of the nature of the voluntary work for which you are applying, you are required to disclose any
criminal convictions which you have had. You are therefore not entitled to withhold information about
convictions which for other purposes are ‘spent’ under the provisions of the Act. Failure to give this
information could result in your dismissal. The Trust, should it be necessary, may carry out a Criminal
Records Disclosure if your placement involves working with certain vulnerable categories of patients. This
information will be treated in strict confidence and will only be taken into account if relevant to the
voluntary placement. Please inform the Voluntary Services Manager of any subsequent convictions.

Do you have any previous or pending convictions? YES / NO (If yes, please give details)

.……………………………………………………

Signature …………………………………………… Date ………………………………………………

CONFIDENTIALITY
I have been advised of the fact and fully understand it is to be a condition of my placement in
Cambridgeshire Primary Care Trust that all information in respect of patients which comes to my
knowledge, directly or indirectly, through the course of my placement shall be treated as confidential and
shall not be discussed with or disclosed to any unauthorised person or persons including the patient or
patients concerned. I understand that breach of this condition of my voluntary service would be regarded
as gross misconduct and will result in disciplinary action (which may, in an appropriate case, involve
instant dismissal). I have also been made aware that a breach of confidence could result in an action for
civil damages.

Signature………………………………………….. Date……………………………………………….

DATA PROTECTION
Please note that by signing this application you give permission for these details to be kept on computer
database. Personal details will not be disclosed to any other body without your prior permission.

DECLARATION

I confirm that the information provided by me on this form is true and correct.

Signature …………………………………………. Date………………………………………………

Please return your application form to:The Voluntary Services Manager, Arthur Rank House,
Brookfields Hospital, 351 Mill Road, Cambridge, CB1 3DF

For Office Use Only

Interviewed by………………………………………… Date………………………………………………..