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Are you over 18 years of age and under 70

Section A : Personal Details

Title »

Last or Family Name »

Forenames »

Date of birth »

Address »

Postcode »

Email address »

Telephone number (home)

Telephone number (mobile)

Use this email for a DBS Check? »

Yes
No

Section B : Emergency Contact

Please give details of someone you would like us to contact in the event of an emergency

First name »

Last name »

Address »

Daytime phone number

Evening Contact number

Relationship to you »

Section C : Character Reference

Please give the name and address of a reference, who have known you for at least two years. They should not be relatives or partners.

1.

Name »

Address

Postcode

Telephone number

Email

Relationship to you

Section D: Volunteering

Do you have any previous voluntary service experience? »

Which area of volunteering would you consider? »

Do you speak any other languages?

Do you have voluntary service experience?

Yes
No

Size for volunteer polo tops

Size for mens shirts

Size for womens blouses

Section E Foundation Trust Membership

If you are already a Foundation Trust member, please enter your membership number if known...

Becoming a Trust volunteer automatically enrolls you as a Foundation Trust member unless you indicate otherwise. Please select 'Yes' if you wish to opt out of becoming a Foundation Trust member

Yes

Section F : Health Declaration

Are you in good health

Yes
No

Are you currently being treated by your GP

Yes
No

Do you suffer from Epilepsy

Yes
No

Do you have diabetes?

Yes
No

Have you been immunised against tuberculosis

Yes
No

Have you been immunised against Hepatitis B

Yes
No

Have you been immunised against Rubella

Yes
No

Have you been immunised against Tetanus (up to date)

Yes
No

Have you been immunised against Polio

Have you been immunised against Covid-19? (both vaccinations)

Yes
No

Have you a lung condition such as COPD, cystic fibrosis or asthma

Have you a condition that makes you more likely to get infections

Are you taking medicines that weakens your immune system

Are you immunosuppressed

Are you receiving treatment for blood and bone marrow cancer

Are you pregnant

Have you had an organ transplant

Are you receiving cancer treatment

Name of GP »

Address of GP »

Telephone number of GP surgery

Section G: Rehabilitation of Offenders Act 1974

Rehabilitation of Offenders Act 1974 The Voluntary work you are applying for involves direct contact with people who are receiving a health service, therefore all prospective volunteers will be required to complete a Disclosure and Barring Service check. In accordance with current legislation (Rehabilitation of Offenders Act 1974) volunteers are not en-titled to withhold any information about convictions which for other purposes are “spent” under the provisions of the Act. In the event of you undertaking voluntary work, any failure to disclose such convictions could result in dismissal or disciplinary action by the Trust. The disclosure of cautions or convictions may not necessarily debar for voluntary work but may influence which placements are available to you. The decision will be in accordance with our Equal Opportunities policy.

Have you any information to declare »

Yes
No

If YES please give brief details of ALL criminal convictions

Section H : Eligibility to work in the UK

I confirm that I am eligible to work in the UK »

Yes
No

Section I : Monitoring information

Ethnic Origin: White

British
Irish

Ethnic origin: Asian or Asian British

Indian
Bangladeshi
Pakistani

Ethnic orgin: Other

Chinese

Ethnic Origin: Mixed

White & Black Caribbean
White & Black African
White & Asian
Other

Ethnic origin: Black or Black British

Caribbean
African
Other

Not stated

Not stated

Religion/Faith

Gender

Sexuality

Disability

We aim where possible to provide equal access and equipment to ensure that volunteering is an inclusive activity. If you require any assistance we will try to help.

Do you consider yourself to have a disability

Section J: About you

Please use this space to tell us a little about yourself and why you wish to volunteer for the Trust. (This information will be shared with managers who interview you.)

Section K : Code of Conduct

Code of Conduct in Respect of Confidentiality for

Non Contracted Staff including Third Party Organisations

During the course of your time in the Trust, you may acquire or have access to confidential information which must not be disclosed to any other person unless in pursuit of your duties or with specific permission given by a person on behalf of the Trust. This condition applies during your relationship with the Trust and after the relationship ceases.

Confidential information includes all information relating to the Trust, its patients and employees. You may come into contact with this information through handling patient’s records, telephone enquiries about patients or staff, electronic database or methods of communication, use of fax machines, handwritten notes made containing patient information or even seeing a person who is known to you attending for treatment, etc. If you are in doubt as to what information may be disclosed, you should check with your manager.

The Data Protection Act 1998 regulates the use of all personal information and together with the Computer Misuse Act 1990 provides criminal offences relating to unauthorised access to such information. Relevant details of these acts can be found in the Trust Information Security Policy, which is available in the work access or on Trustnet. If you are found to have made unauthorised access to or disclosure of personal information you may face legal action.

I understand the above, and that I am bound by a duty of confidentiality and agree to adhere to this code of conduct and the requirements of the Data Protection Act.

Yes
No

Section L : Confidentiality and data protection

I understand that anything I hear or learn concerning patients, relatives, careers or staff in the course of my duties as a volunteer within the East Kent Hospitals University NHS Foundation Trust must be treated in the strictest confidence, and I agree to the code of conduct under the Data Protection Act 1999

Yes
No

I agree to be registered as a Volunteer and to abide by the guidelines concerning the duties of volunteers contained in the Volunteer Services policy.

Yes
No

I declare that the information given on this form is true and complete to the best of my knowledge and belief.

Yes
No

I understand that any information given by me will be treated as confidential and only be used in relation to my voluntary work.

Yes
No

I agree for my information being used to enrol me as a foundation trust member. I understand that information used for this purpose will not be shared without my consent with third parties.

Yes
No

Please contact the team by email ekh-tr.volunteers@nhs.net for more details. We will be in contact with you to arrange an interview.

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