End of Life Project Volunteer Application Form

Your Details

Gender *

Person to notify in case of emergency

Please remember to keep us informed of any changes so that our records are kept up-to-date

Occupational Health Disclosure

Please review and answer the following statements. (Please tick the answer that applies to you). *
If you do indicate that you have a health condition or disability then our Occupational Health Team will make contact with you before you start. Contact may also be made by Occupational Health if your references raise any health conditions or information which might affect your volunteering.

References

We do need to take up references so please give the names and addresses of two referees. If you are currently, or have recently been in employment or involved in any voluntary work, one of your references should be from that organisation. References must be from people who are over the age of 18 and who have known you for at least 2 years. Relatives or partners cannot act as referees.
We do need to take up references so please give the names and addresses of two referees. If you are currently, or have recently been in employment or involved in any voluntary work, one of your references should be from that organisation. References must be from people who are over the age of 18 and who have known you for at least 2 years. Relatives or partners cannot act as referees.

Rehabilitation of Offenders Act 1974

The organisation aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. The organisation undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.
You will need to complete a Disclosure & Barring Service criminal record disclosure for this position because you will have direct contact with vulnerable adults and/or children when you volunteer. You are required to declare all current unspent criminal convictions or cautions (including reprimands and final warnings). In addition, you are required to disclose spent convictions, cautions, reprimands or final warnings unless they are protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013). You are not required to tell us about parking offences.
The organisation aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. The organisation undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. You will need to complete a Disclosure & Barring Service criminal record disclosure for this position because you will have direct contact with vulnerable adults and/or children when you volunteer. You are required to declare all current unspent criminal convictions or cautions (including reprimands and final warnings). In addition, you are required to disclose spent convictions, cautions, reprimands or final warnings unless they are protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013). You are not required to tell us about parking offences.
Are you bound over or do you have any convictions, cautions, reprimands or final warnings that are not protected? * *
Are you currently bound over or do you have any current unspent convictions or cautions? *
Are you currently bound by any barring decision made by the Disclosure Barring Service (DBS) from working with children or adults?
Answering yes will not necessarily bar you from volunteering. This will depend on the relevance of the information you provide in respect of the nature of the position for which you are applying and the particular circumstances. Please call us if you would like to discuss further - we are here to help. You can also look at the guidance on the Disclosing and barring website at: www.gov.uk/government/organisationsdisclosure-and-barring-service

The Race Relations (Amendment) Act 2000 is the piece of primary legislation that directs public bodies to collect information on ethnic origin. I would describe my ethnic origin as:

Asian or Asian British

Black or Black British

Mixed

White

Other Ethnic Group

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Photo consent

This section is designed to protect our volunteers, patients, visitors, members of the public, staff and our agents from unwarranted harm or exploitation. Please read the declaration below.

You may be photographed by Dorset HealthCare University NHS Foundation Trust or their PR agents for the sole and exclusive use - with or without a name or names - of publicising Dorset HealthCare activities in the local and/or national media for public relations/marketing/advertising purposes. The resulting photograph(s) will only be used to illustrate Dorset HealthCare brochures, letterheads, leaflets, posters or similar written materials.

I understand that I have no interest in the copyright, nor any moral rights, in the photograph and have no rights to benefit financially from publication of any photograph(s).
This section is designed to protect our volunteers, patients, visitors, members of the public, staff and our agents from unwarranted harm or exploitation. Please read the declaration below.

You may be photographed by Dorset HealthCare University NHS Foundation Trust or their PR agents for the sole and exclusive use - with or without a name or names - of publicising Dorset HealthCare activities in the local and/or national media for public relations/marketing/advertising purposes. The resulting photograph(s) will only be used to illustrate Dorset HealthCare brochures, letterheads, leaflets, posters or similar written materials.

I understand that I have no interest in the copyright, nor any moral rights, in the photograph and have no rights to benefit financially from publication of any photograph(s).

Confidentiality

In the discharge of your duties while volunteering at Dorset HealthCare you may be in possession of or have access to confidential information about the Trust, its policies, plans, practices, finances, staff and patient records. In accordance with the provisions of the prevailing Data Protection Act, including the General Data Protection Regulation (GDPR), the NHS Confidentiality Code of Practice, Caldicott Principles, the Trust’s own IT Acceptable Use Policy and Information Governance Policy you must not disclose or discuss such information outside your place of volunteering activity.

In addition, you must not disclose or discuss such information where you volunteer except in the proper discharge of your duties.

If you require advice or guidance about your responsibilities in relation to confidentiality you should seek further advice from your line manager/supervisor or the Volunteer Coordinator who is based within the Organisational Development Participation & Communications Directorate

Personal declaration

I understand:
  • The appointment if offered will be subject to the information given on this form being correct
  • My obligations in respect of disclosure of information and that the appointment may be subject to a medical examination
  • I will not receive payment for my voluntary work
  • I understand that the voluntary work I do will be of a confidential nature and that anything I see or hear must be treated with the strictest confidence. My volunteering may involve issues and situations of a sensitive nature and I agree to maintain confidentiality at all times.
    • If you require advice or guidance about your responsibilities in relation to confidentiality you should seek further advice from the Volunteer Coordinator.
  • The Trust complies with the terms of the Data Protection Act 1998. All information held is in a confidential manner.
  • I must abide by the Dorset HealthCare University NHS Foundation Trust volunteer guidelines.
  • Volunteers are bound by the Health & Safety at Work Act.
  • The Trust reserves the right to request a Disclosure and Barring Service check at any time during your volunteer service.

Agreement and Signature

I confirm the information provided is accurate and up to date *
As a Trust we meet GDPR requirements. We only capture this data for the sole purpose of processing your application. Please refer to our privacy notice for more detail. *National insurance number is required solely for the purpose of applying for a DBS (Disclosure and Barring Service) check. Thank you for completing this application form and for your interest in volunteering.
Palliative care volunteering project in Purbeck area