PLEASE ENSURE ALL QUESTIONS ARE ANSWERED BEFORE SUBMITTING THE FORM.

Are you over 18 years of age and under 70 ^*

Yes No

Section A: Personal Details

Title ^*

Last or family name

Forenames ^*

Date of birth ^*

Day

Month

Year

Address ^*

Postcode ^*

Telephone number (home or mobile) ^*

Email address ^*

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 or family name ^*

Address ^*

Telephone number (home or mobile) - Daytime ^*

Telephone number (home or mobile) - Evening ^*

Relationship to you ^*

Section C: Character Reference

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

Referee 1 - Name ^*

Referee 1 - Address ^*

Referee 1 - Postcode ^*

Referee 1 - Telephone number ^*

Referee 1 - Email ^*

Referee 1 - Relationship to you ^*

Referee 2 - Name ^*

Referee 2 - Address ^*

Referee 2 - Postcode ^*

Referee 2 - Telephone number ^*

Referee 2 - Email ^*

Referee 2 - Relationship to you ^*

Section D: Volunteering

Employment ^*

Full time Part time Retired Student Unemployed Other (please state below)

Please state your employment type

Do you speak any other languages? Please state which ones

Do you have any previous voluntary service experience?

Yes No

Approximate hours per week (Maximum 16 hours) you would be able to volunteer

Days and times preferred?

Size for male and female polo shirts

S

M

L

XL

XXL

N/A

Size for male cotton shirts

15

15.5

16

16.5

17

17.5

N/A

Size for female blouses

10

12

14

16

18

N/A

A variety of sizes may be available on request.

Section E: Foundation Trust Membership

Please note - Becoming a Trust volunteer automatically enrols you as a Foundation Trust member.

Do you wish to enrol as a Foundation Trust Member? ^*

Yes No

https://www.ekhuft.nhs.uk/get-involved/become-a-member/

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? ^*

Yes No

Have you been immunised against Covid? ^*

Yes No

Name of GP ^*

Address of GP ^*

Email address of GP ^*

Telephone number of GP Surgery ^*

Section G: Rehabilitation of Offenders Act 1974

Guidance on the Rehabilitation of Offenders Act 1974 and the Exceptions Order 1975 - GOV.UK (www.gov.uk)

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
entitled 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

Please enter Not applicable if this does not apply to you.

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

I would describe my ethnic origin as:

Asian or Asian British

Bangladeshi

Indian

Pakistani

Chinese

Any other Asian background

Black or Black British, Caribbean or African

African

Caribbean

Any other Black, Black British or Caribbean background

Mixed or Multiple Ethnic Groups

White & Asian White & Black African White & Black Caribbean Any other mixed or multiple ethnic background

Other Ethnic Group

Arab

Any other ethnic group

White

English, Welsh, Scottish, Northern Irish or British

Irish

Gypsy or Irish Traveller

Roma

Any other White background

I do not wish to disclose my Ethnic Origin

Gender

Male

Female

Non-binary

I do not wish to disclose this

Sexual Orientation

Please select which sexuality applies to you:

Heterosexual

Gay or lesbian

Bisexual

Prefer not to state

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 or long-term health condition? ^*

Yes (please complete the section below)

No

Please state the type of disability / impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Physical Impairment

Sensory Impairment (hearing / sight)

Lived experience of mental health

Learning Disability/Difficulty

Long-Term Health Condition

Neurodiversity (Autism, AH, ADHD, Dyslexia, Dyspraxia)

Section J: About you

Please use this space to tell us a little about yourself and why you wish to volunteer for the Trust. ^*

Section K: Code of Conduct

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, ward whiteboards, telephone enquiries about patients or staff, electronic database or methods of communication, , handwritten notes made containing patient sensitive health 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 2018 and UK General Data Protection Regulations (GDPR) regulate the use of all personal information and together with the Computer Misuse Act 1990 provide criminal offences relating to unauthorised access to such information. Relevant details of these acts can be found in the Trusts Data Protection, Information Governance and Information Security Policies, which are available in the work access or Trust Intranet. If you are found to have made unauthorised access to or have disclosure staff or patient personal information you may face legal action.

Data protection: The Data Protection Act - GOV.UK (www.gov.uk)

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.

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.

I agree to the code of conduct under the Data Protection Act 2018 and UK General Data Protection Regulations.

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.

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

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

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.

Please ensure you have completed ALL the required fields (marked with ») or your form will not be submitted.

Volunteer application