Expression of interest form to apply

to become a member of Voices4Care

About this form

Thank you for your interest in becoming a member of Voices4Care. Members ofVoices4Care will include:

  • people receiving palliative care (patients/service users),
  • people with current or previous caring experience, and
  • citizens with a general interest in palliative care.

We advise that you would wait at least 12 months followingbereavement before considering applying for membership of Voices4Care.

Please note

  1. Please read the Guidance for Applicants information before completing this form.
  2. Please complete this form by typing or writing clearly in black ink.
  3. We will treat the information you give us as confidential.This information will be used to enable the selection group to select a diversity of people from a variety of backgrounds.
  4. If you have any questions about completing this form,please contact All Ireland Institute of Hospice and Palliative Care on (+353) 1 4912948 or
  5. Please email or post your completed expression of interest form by Tuesday 9 August 2016to:

Email:

Or by post to:Brendan O’Hara

All Ireland Institute of Hospice and Palliative Care

Second Floor, Education & Research Centre

Our Lady’s Hospice

Harold’s Cross

Dublin 6W

Expression of Interest Form

to apply to becomea member of Voices4Care

Name
Address
Home Tel
{Day Time} / Mobile Tel
Email
Gender / Age / years

How did you hear about Voices4Care? (for example, events, leaflet, advertisement, media interview; newspaper story, internet and so on).

d

A patient/service user

A carer/former carer

An interested citizen

  1. Motivation

Please outline why you would like to be considered for membership of Voices4Care?

2. Experience and Skills

Please give a broad outline ofrelevant experience, skills and or interests that you hope to contribute as a member of Voices4Care? You can give examples from your personal and or professional life.

3. Availability and Engagement(we are exploring how to involve people as best as possible and are looking at a range of methods)

Please tick as appropriate:

I am a resident of: Northern Ireland Republic of Ireland

I am able and willingto attend meetings at venues across the island of Ireland

I am able and willing to attend meetingsup to three times per year

I am able and willing to be involved in meetings through the use of new technology, for example videoconferencing, skype etc.

I am able and willing to receive and comment on written material, for example, reports

I am willing to be involved for up to 24 months*

I am willing to be contacted by telephone for my views and or comments

I am willing to be involved on a voluntary basis

Please make any additional comment about your ability to be involved in Voices4Care?

Do you have access to email Yes No

Are you comfortable using email Yes No

Please note that we will send printed information to Voices4Care members, where required.

Have you any mobility or other needs which it would be helpful for us to be aware of?

Yes No

If yes, please describe what you need us to consider

If you are shortlisted, we will try to accommodate your needs where possible.

Declaration

I declare that the information I have given in this form is correct.

Signed: (if you are emailing this form we will assume that you are declaring that the information is correct)

Date:

Please email or post your completed form (contact details on front page).

If there are more applicants than places available on Voices4Care, please indicate if you are happy for us to keep this form on file should places become available over the next two years. Please tick the appropriate box below.

Yes No

Thank you for your interest. We will acknowledge receipt of your Expression of Interest Form.