Buddy Volunteer Application Form

Buddy Volunteer Application Form

Personal Information

Title / First Name / Middle Name
Last Name / Known As
Address
Town / County
Postcode / Date of Birth
Home Phone / Mobile Phone
Work Phone / Email Address

Feedback

Where did you hear about volunteering for Chestnut Tree House?

Availability

Which group are you available to carry out your volunteering? (Please indicate)

(NB: 15+ and 18+ denotes minimum age required to carry out role. 1:1 days and times to be arranged with parents / carers)

Saturday Youth Group (15+) 1:1 Buddy (18+)

Interests

Tell us what interest and activities you like doing. (Please indicate)

Arts & Crafts /
Cooking /
Singing

Bowling /
Make-up and Pampering /
Sports

Cinema /
Music /
Swimming

Zoo
Any other interests (please give details):

Skills, Qualifications and Hobbies

Summarise skills and qualifications you have acquired from employment, previous volunteering, or through other activities, including hobbies or sports.

Previous Volunteer Experience

Summarise any previous volunteering experience you have.

Supporting Statement

Please use the space provided to say why you would like to be a Volunteer Buddy at Chestnut Tree House and describe what experience, skills or personal qualities you feel you would bring to the role. Please also include what you hope to gain from volunteering with Chestnut Tree House.

Driving Licence

Do you hold a clean, current driving licence? Yes No

If No, please give details:

Are you a car owner? Yes No

Do you have access to a car to use for voluntary work purposes? Yes No

Please give details:

References

Please provide the details of two people we can write to for a personal reference (not family members).

Title / First Name / Last Name
Address
Town / County
Postcode / Email
Title / First Name / Last Name
Address
Town / County
Postcode / Email

Emergency Contacts

Please provide the details of two people we can contact in case of emergency.

Title / First Name / Last Name
Home Phone / Mobile Phone
Work Phone / Relationship to you
Lives at same address / Yes / No
Title / First Name / Last Name
Home Phone / Mobile Phone
Work Phone / Relationship to you
Lives at same address / Yes / No

Data Protection

I agree to your holding and processing, electronically and by paper records, personal data and information about me. I understand that this information is collected for the purposes of managing and administering your staff and volunteers, if necessary for your business operations and/or compliance with applicable laws and regulations. I also consent to the storage, transfer and processing by you of such data.

I understand that the records you hold and process may include, personal details (including the medical questionnaire) and that such information and data is held securely within the Hospice records whilst I am undertaking volunteer work and for 6 years after having ceased this volunteer duty at which time the records will be destroyed. Personal Data and processing is as defined by the Data Protection Act 1998. I agree to adhere to the Data Protection Policy of the Hospice.

Confidentiality

I understand everything that I hear or learn in the course of my duty as a volunteer at Chestnut Tree House / St Barnabas House must be treated in the strictest confidence and should be considered as confidential unless I am specifically told otherwise. This must include information regarding individual patients, families of patients, staff, donors, supporters, colleagues and the activities of the hospice.

By confidential I understand that I must not share this type of information with anyone outside of the hospice even families and friends.

I agree that my duty to confidentiality continues indefinitely even after I have stopped my volunteering duties at the hospice.

Our Policy

St Barnabas Hospices use the Disclosure and Barring Service (DBS) to assess volunteers’ suitability for working with children or vulnerable adults. We comply fully with the DBS Code of Practice and undertake to treat all applications to become a volunteer fairly. We undertake not to discriminate unfairly against any subject of a Disclosure on the basis of conviction or other information revealed.

If you have any unspent criminal convictions please write to the Voluntary Services Manager at St Barnabas House under separate cover giving details. Having a criminal record will not necessarily bar you from volunteering with us. This will depend upon the nature of the position and the circumstances and background of your offences.

St Barnabas Hospices is committed to the fair treatment of its volunteers, potential volunteers regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability, offending background or relationship status.

Agreement and Signature

I agree to be enrolled as a volunteer and to abide by the Volunteer Guidelines and Hospice Policies. I declare that the information given on this form is true and complete to the best of my knowledge and beliefs.

Name (printed) /
/ Date
Signature

Registered charity number 256789