VOLUNTEER APPLICATION FORM
Section A – About You:
Title: / Surname: / First names:
Home address: / Telephone:
Mobile:
email:
Post code: / Date of birth: / Male □ Female 
Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) national? / Yeso
Go to
Section B / No o
Visa no: / Start Date: (dd/mm/yy)
Expiry date: (dd/mm/yy) / Details of restrictions:
Does your visa allow you to volunteer in the UK? / Yeso No o
Section B - Emergency Contact
Surname / Forename
Address / Relationship to you
Home telephone / Work telephone
Mobile telephone
Section C - Employment Information. Are you:
In full time employment
In part time employment / ¡
¡ / Seeking employment
Retired / ¡
¡ / Seeking a career in the NHS
Seeking to fill some spare time / ¡
¡
Other (please specify) / ¡
Student - full time / part time Course name: / ¡
Section D – Availability for volunteering

Volunteering requires regular commitment. We ask for a regular commitment of one shift per week. Please indicate your availability below:

Morning / Afternoon / Evening
(Wards only) / Morning / Afternoon / Evening
(Wards only)
Monday / Thursday
Tuesday / Friday
Wednesday / Saturday/
Sunday
(wards only)
Section E - References
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. Other references may be from people who are in a position of authority, are over 18 and who have known you for at least 2 years. Relatives or partners cannot act as referees.
Name
Address
Telephone
e-mail / Name
Address
Telephone
e-mail
Section F – Health Declaration
Please answer the following questions by ticking the appropriate box:
I am not aware of any health condition or disability that might impair my ability to undertake voluntary work with the Trust / o
I do have a health condition that might affect my volunteer work and that might require special adjustments at my place of work.* / o
*If yes, what support or adjustments do you think you will need to attend interview?

Any information you provide will be treated in confidence but will help us to plan your involvement properly.

We need to keep you and our patients safe so in order to volunteer, you will be asked to complete a short health questionnaire. This may result in you being asked to see the occupational health doctor.

Section G - Criminal Convictions
Because of the nature of healthcare work, volunteers are exempt from the Rehabilitation of Offenders Act 1974. This means that you must declare any convictions, cautions or reprimands you have had.
Have you ever been cautioned or convicted of an offence? / ¨ Yes ¨ No ¨ Not sure
If Yes, we will need to understand the details of what happened. If you are unsure how to answer this question please contact us for advice. Any information you give us will be treated in the strictest confidence.

Volunteers may be required to complete a disclosure application for the Disclosure and Barring Service.

Section H – Personal statement
Please tell us why you think you are suited to the opportunity you are applying for. Please include any relevant experience.
Section I – Typical volunteer roles
PLEASE TELL US WHICH VOLUNTEER OPPORTUNITY YOU ARE INTERESTED IN.
Please note that these are examples of our opportunities and they may not always be available
Typical volunteer roles:
Patient companions – Lister Hospital - Help around the ward by making refreshments, running errands, completing menu cards. Chatting to patients is an important part of this role. Assisting patients who need help at mealtimes (on relevant shift) by opening packets, cutting up food and feeding.
3 hour shifts - Days: Monday -Sunday: 08:00-11:00, 11:00-14:00, 14:00 -17:00 or 17:00-20:00 / ¡
Department assistants – Duties vary from dept. to dept. Can include greeting patients, making refreshments, making up beds, topping up cupboards, running errands, collecting TTOs from pharmacy and completing surveys. 3 hour shifts.
Days: Mon – Fri 09:00 – 16:00 / ¡
Hospital guides – Lister Hospital -working alongside reception staff, escorting patients round the hospital site.
Days: Monday – Friday: 09:00 – 12:30 and 12:30 – 16:00 / ¡
Ward activity volunteers – Lister Hospital - Working with elderly patients, these volunteers organise activities to stimulate patients e.g. chatting, playing games, singing.
Days: Wednesday 14:00 – 16:00 / ¡
Macmillan support volunteers – Lister Hospital - meeting and greeting service users, explaining resources available and assisting with clerical duties in the Macmillan information centre.
Days: Monday-Friday 10:00-13:00 or 13:00 – 16:00 two volunteers per session. Must be a minimum of 2 yrs post treatment (self or family). / ¡
Macmillan Chemotherapy Unit - Lister Hospital – usually working in pairs, this group of volunteers chat to patients and make tea and coffee for those waiting for clinic appointments or having their chemotherapy.
Days: Mondays to Fridays - mornings or afternoons / ¡
Sunday service volunteers – Lister Hospital - A rota of volunteers supporting the hospital chaplains by taking patients to Sunday chapel and assisting them during the service.
Days: Sundays 09:00 – 12:00 / ¡
Admin volunteers - supporting clerical staff by undertaking routine tasks. Some of these roles require basic PC skills
Days: Monday to Friday - office hours. / ¡
Fundraising supporters – Lister Hospital - Assist with community fundraising events under the direction of the fundraising team. May be involved in some basic clerical duties. / ¡
Carer’s support team - working alongside our carers’ lead, ensuring that carers have the information and support they need. / ¡
Complementary therapists – Lister Hospital - qualified complementary therapists offering energy therapy to patients. / ¡

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

Please return this form to: Voluntary Services Department, East and North Herts NHS Trust

L33 Lister Hospital

Coreys Mill Lane

Stevenage

Herts SG1 4AB

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