Application Form For Volunteers

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: [email protected]

Website: www.arthurrankhouse.nhs.uk

CONFIDENTIAL APPLICATION FORM FOR VOLUNTEERS Personal Details: Title:

Mr / Mrs / Miss / Ms / Other………...

Address: 3-3-4 Brookside Cambridge ………………………………………

Surname: …. Forenames: …………….

………………Ta……………………

…………………………………….……………..

…………………………Ngan

…………………………………….……………..

………………………………………

Postcode: ………..

Age:

up to 18 / 18 – 64 / 65 and over (this information is required in order to comply with Health & Safety regulations)

CB2 1JE……………………………

Tel home: ……01223 350158 ……………………………….…. Mobile:

………………………………………...

Work:

………………………………………..

Email: …[email protected]………… …………………………. Contact in case of accident or emergency: Name: Truong Viet Anh Hong …………………………………….………… ……………………………………

Tel: 38982913…………

Employment/Educational Status: Are you currently in full-time education?

YES / NO

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

……………MPW CAMBRIDGE ………………

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: I was a volunteer in a charity group at my old high school. It is A4C ( Acting for the community) group. We raise fund for the poor children and elders

I love children and want to take care of others

Can you speak any foreign languages? If so, which? Yes, I can speak Vietnamese and English

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

YES / NO

Would you be prepared to use your car to transport patients/visitors/equipment as part of your voluntary work? YES / NO / POSSIBLY

Are you registered disabled?

Do you have special requirements to enable you to carry out voluntary work? ……………………………………………………

…………………………………………………… 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? Website Please state why you are interested in becoming a hospice volunteer: lI ove caring others and want to apply to a Medicine school in the future. Thus, I think it is very good for me to be a volunteer.

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

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

Bereavement: Have you suffered any bereavement? No 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)………………………………………………

…………………………………………….

…………………………………………………

……………………………………………..

…………………………………………………

……………………………………………..

.…………………………………………………

Post Code: …………………………………………….

…………………………………………………

Tel No:

…………………………………………………

Address:

..…………………………………………..

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 ……Ta Hong Ngan ………………………………………

Date …………28/07/09……………………………………

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………Ta Hong Ngan …………………………………..

Date………28/07/09

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 ………… Ta Hong Ngan ………………………………. 28/07/09………………………

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………………………………………………..