Office Use Only
Barts Charity is the official charity for Barts Health NHS Trust, covering Barts, Mile End, Newham, The Royal London, and Whipps Cross hospitals, plus services in the local community.
Please state below which hospital you are applying for (Does not apply to office based roles)
Contact details
Miss Ms Mrs Mr Other (please state)
First Name
Last Name
Address
(including postcode)
Home Tel
Mobile
Email
Date of Birth

Please tick the times and days of the week that would be most convenient for you to volunteer

(Please note that some flexibility is required):

Mon / Tues / Wed / Thurs / Fri
Morning
Afternoon
Visa/ Permit
Do you need a work permit to work in the United Kingdom? Yes No
If you currently hold a work permit or visa, please give details including its type and expiry date:
Have you lived in the UK for the last year? Yes No
If you have lived in the UK for less than 1 year do you hold a certificate of good conduct from the other countries you lived in? Yes No
If no, are you willing to obtain one? Yes No

How did you hear about the volunteer role?

Charity website Other Website Friend Facebook Hospital flyer/poster

Other (please specify)

Relevant Information
Why do you want to volunteer for Barts Charity and this role in particular?
What skills and experience can you bring to the role? Please include paid and voluntary experience as well as skills that might be useful for the role (e.g. languages, customer service skills). Please continue on to another sheet if necessary.
Is there any other information which you think is relevant to your application?
Emergency Contacts
Name / Telephone Number / Relationship to you

References

Please give the names and addresses of two referees who have known you for a year or more, other than relatives, one of whom should be your present or most recent employer/line manager. Students may give the name of a course tutor/lecturer. Long term unemployed applicants may provide the name of a personal referee e.g. neighbour.

Referee 1 / Referee 2
Name / Name
Address / Address
Tel / Tel
Email / Email
How does the referee know you?
(e.g manager) / How does the referee know you?
(e.g manager)
How long have you known them? / How long have you known them?

Criminal Convictions

Posts entailing contact with patients are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974. This means applicants are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act. You should also declare if you have ever received a caution, reprimand or warning. If you are accepted to undertake voluntary work and fail to disclose such convictions, this could result in your dismissal. Please provide information on a separate sheet. Any information given will be completely confidential and will be considered only in relation to any application for voluntary positions to which the order may apply.

Do you have any criminal conviction(s)? Yes No

(If yes please provide information on a separate sheet)

Confidentiality Clause
I will under no circumstances divulge or pass on any personal or confidential information to any unauthorised person or persons; any matters of a confidential nature including information relating to diagnosis and treatment of patients, individual staff records and details of contracts, prices and terms, that I may receive during the course of my voluntary work. I understand that if I breach confidentiality, do not keep to the volunteer role guideline or do not conduct myself in appropriate manner my voluntary work will be terminated.
I understand that I will only be eligible for a certificate of attendance and a reference upon completion of 24 sessions of volunteering. I understand that at any time I may be asked to leave my voluntary placement if my performance is not satisfactory.
I understand that this is a voluntary role and does not constitute employment per se and there will not be an entitlement to any form of payment on its cessation. Employment with the Charity is not guaranteed in any way or conferred by this application form.

I understand that the voluntary place offered will be subject to the information on this form being correct.

Signed: Date:

Thank you for taking the time to complete this form and for your interest in volunteering for Barts Charity!

Equal Opportunities Monitoring Form

Barts Charity wants to build a diverse volunteer base and is committed to a policy of equal opportunities for all. In order to monitor our equal opportunities policy we need to know the proportions of males and females, of different ethnic groups and of people with disabilities within our volunteer programme. This form will form NO part of the selection process. The information in this form will be held in strictest confidence and in accordance with the Data Protection Act 1998.

Gender: Male Female

In which of these categories do you consider yourself to be?

White / Asian or Asian British / Other ethnic groups
British / Indian / Chinese
Irish / Pakistani / Cypriot – Greek
Any other White background / Bangladeshi / Cypriot – Turkish
Any other Asian background / Filipino
Mixed / Greek
White & Black Caribbean / Black or Black British / Somali
White & Black African / Caribbean / Turkish
White and Asian / African / Vietnamese
Any other Mixed background / Any other Black background / Any other ethnic group

Do you consider yourself to have a disability? (The Trust welcomes applications from people with disabilities)

Yes No

If yes, please let us know what sort of support you would require to become a volunteer?

Are you currently?

Employed full time Employed part time House Husband/Wife

Looking for work Retired Student part time

Student full time Unable to work Other (please specify)

Registered charity no. 212563