Surname: / Title: Mr/Mrs/Miss/Ms:
First name: / Maiden name: (if appropriate)
Home Address:

Post Code

Tel No:
Do you have a current driving licence? Yes/No / Do you have access to a car?

Are you: (please tick)

Employed Unemployed Student Homemaker

Retired Other

Please indicate how you became aware of the volunteer scheme in the Trust.

Volunteer Poster/LeafletTrust Staff Trust Website

Other volunteer Outside organisation Other, please specify

Preferred type of Voluntary work:

Briefly outline your Skills/Interests:

Previous employment or volunteer experience (if appropriate)

Is there any additional information about your background or previous experience, which you feel would help us to match you to a suitable role?





Have you been convicted of any criminal offences, cautions or bound overs, or cases pending against you? YES/NO (delete as appropriate)

If yes, please provide details:

NB A criminal conviction will not automatically debar an individual from volunteering. Please note that no conviction can be considered as spent for employment within the Health Service. All offences must be disclosed.

All suitable applicants will be asked to complete an Access NI Vetting Check

Occupational Health: Successful applicants will be asked to complete a Health Declaration form and attend for an Occupational Health assessment.

The DDA defines disability as "a physical or mental impairment which has a substantial long-term adverse effect on his / her ability to carry out normal day to day activities".

Do you have a disability? Yes / No

If Yes, do you feel your disability would prevent you from fulfilling any particular volunteer roles? Give details

Do you need to have any special arrangements made for you to attend for interview?

Yes / No ______

Please note this will not affect your suitability to become a volunteer, the information is important in order that you can be matched to a suitable role in line with your disability

Please name two referees one of whom should have knowledge of past work experience if appropriate. (Not: relatives/in-laws/close friends).

(One of which must be someone who has knowledge your work in a supervisory/managerial capacity, or if never employed, someone who knows you well enough to comment on your ability to do the volunteer role for which you have applied. The Trust does however reserve the right to contact any of the previous employers listed on the application form.)

Name: Name:




Daytime Telephone Number:Daytime Telephone Number:

Personal Declaration

  • I declare the information on this form to be true and complete. I understand any wilful mis-statement or omission renders me liable to disqualification for voluntary work.
  • I also understand that the appointment as a volunteer is subject to satisfactory references/vetting and Health Check. I confirm to the best of my knowledge there is no medical reason which would prevent me from undertaking the position of volunteer.
  • I am aware that if my application is successful a minimum commitment of 9 months is required.

Signature: ______Date: ______

Please return completed application form to:

Volunteer Services

Room 1.11

1st Floor

McKinney House

Stockman’s Lane



Phone 028 95048596