Volunteer Application form

First name(s)

Surname:

Address Postcode:

Home tel. No. Mobile tel. no.

National Insurance Number:

Date of Birth:

Email address:

(Please print)

Current place of
work/study

Name of next of kin Relationship:

Tel no. of next of kin

The following roles are available:

Role Oldham Hospital Rochdale Infirmary

Dining Companion ✔ ✔

(available 7 days a week)

Responder X ✔

(available Mon-Fri)

Please state which role and which hospital you are interested in volunteering at

Role Hospital

What days and times are you able to commit to volunteering? (Please tick)

Dining Breakfast (approx Lunch (approx Tea (approx.

Companion 7am–9am) 11.30am – 1pm) 4.30pm – 6pm)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Responder role 8-12 12-4

(only available at
Rochdale Infirmary)
Monday
Tuesday
Wednesday
Thursday
Friday
Why do you want to volunteer?

What qualities can you offer to support your volunteering application?

How will you be travelling to site/community to undertake your volunteering role?

Walk □ Car □ Public Transport □ Motorbike □ Push bike □

References

You will need to supply us with 2 references.

Please state the names and contact details of the people who have agreed to supply references
covering a minimum of 3 years employment/training.

If you are or have been employed, these should include your two most recent employers, your line
manager or someone in a position of responsibility who can comment on your work experience,
competence, personal qualities and suitability for the role as a volunteer.

If you are a student please provide contact details of a teacher or tutor at your school, college or
university (some colleges insist on consent beforehand from the student so please ensure you have
done this if applicable to your college).

If you have not been in employment for a considerable amount of time, but have had previous
employment, then you should seek one reference from your last known employer and a personal
reference from a person of some standing within your community i.e. doctor, solicitor, MP etc.

Where it is not possible to obtain any employer reference at all, then please obtain two personal
references.

Where no personal reference can be obtained, then references should be sought from personal
acquaintances not related to or involved in any financial arrangement with you.

If you have undergone training to return to work then the academic institution should be contacted. If
you are, or have been employed one of these should be your most recent employer and one from
someone from your faith/belief community. Personal references such as relatives are not
acceptable.

Referee 1

Surname First Name

Title

Address

Post Code

Telephone

Job title

Email

Relationship to you
Referee 2

Surname First Name

Title

Address

Post Code

Telephone

Job title

Email

Relationship to you

We contact your referees by email, so please ask them to check their junk/spam inbox as
sometimes our emails are directed there, as this could potentially delay your application.

Once completed, please return this form via email to [email protected]

and the relevant site lead will begin the recruitment process.

Rehabilitation of Offenders Act

Please give details of any spent convictions, prosecutions pending or criminal convictions you may
have had for which you have not yet been rehabilitated as volunteering can involve direct contact
with people who are receiving a health service. Any such information will be treated entirely
confidentially and will be considered only in relation to applications for positions covered by the
Rehabilitation of Offenders Act 1974 (Exceptions Order 1975).

Have you at any time received, or had any criminal convictions, cautions, reprimands or final
warnings?  Yes  No
If yes, enter details (i.e. date, type of offence/sentence/fine imposed etc.):
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
 Declaration of Confidence

I confirm that I will hold in the strictest confidence any personal information concerning patients
which may become known to me during the course of my duties as a volunteer in any of the
hospitals of The Northern Care Alliance NHS Group and that I will not divulge such information nor
discuss it with colleagues in any public place.

I understand that personal information includes a patients diagnosis and treatment and any other
particulars relating to his/her condition. I also understand that any disclosure of such confidential
information by me will result in the termination of my duties as a volunteer.

I have read and understand all of the above, and certify that the information on this form is true and
complete. I agree that any deliberate omissions, falsification or misrepresentation in the application
form will be grounds for rejecting this application or subsequent dismissal if employed by the Trust.
This applies equally to any medical questionnaire/forms I may complete.

Signature: …………………………………………………… Date: ………………………………

Disability Discrimination Act 1995

The Disability Discrimination Act protects disabled people. This includes people with long-term
health conditions. If you tell us that you have a disability we can make reasonable adjustments to
where you volunteer.

 Yes
Do you consider yourself to have a disability?
 No
 I do not wish to disclose this information
Please state the type of impairment which applies to you. People may experience more than one type
of impairment, in which case you may indicate more than one. If none of the categories apply, please
mark ‘other’.
 Physical Impairment  Learning Disability/Difficulty
 Sensory Impairment  Long-standing illness
 Mental Health Condition  Other

Please indicate if you will need any adjustments making when you attend for an interview:

Monitoring Information
 This section of the application form will be detached from your application form and will be used for
monitoring purposes only.

The Northern care Alliance NHS Group recognise the benefits of a diverse team of volunteers and is
committed to treating all volunteers with dignity and respect regardless of race, gender, disability,
age, religion or belief. We therefore welcome applications from all sections of the community.

Date of Birth
 Male  Female  I do not wish to disclose this

Gender
 Other please state………………………………………………….

Do you consider yourself to be?

☐ Bisexual ☐ Gay man ☐ Lesbian/gay woman
Sexual orientation
☐ Heterosexual/straight ☐ Other (please state below) ☐ I do not wish to disclose this
……………………………………………………………………………

Is your gender identity the same as the gender you were assigned at birth?
Gender Identity
☐ Yes ☐ No ☐ I do not wish to disclose this

Race Relations (Amendment) Act 2000

I would describe my ethnic origin as:

Asian or Asian British Mixed Other Ethnic Group
 Bangladeshi  White & Asian  Chinese
 Indian  White & Black African  Any other ethnic group
 Pakistani  White & Black Caribbean
 Any other Asian background  Any other mixed background  I do not wish to disclose this
Black or Black British White
 African  British
 Caribbean  Irish
 Any other Black background  Any other White background

Employment Equality Regulations 2003

Please indicate your religion or belief

 Atheism  Jainism  Judaism
 Buddhism  Sikhism  Hinduism
 Christianity  Other  I do not wish to disclose this
 Islam