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 ^*

Address ^*

Postcode ^*

Email address ^*

Telephone number (home or 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 ^*

Telephone number (home or mobile) ^*

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

Do you have any previous voluntary service experience? ^*

Yes No

Do you speak any other languages?

Which area of volunteering would you consider? ^*

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

Days and times preferred? ^*

Size for volunteer polo tops ^*

S

M

L

XL

XXL

N/A

Size for mens shirts ^*

15

15.5

16

16.5

17

17.5

N/A

Size for womens blouses ^*

10

12

14

16

18

N/A

Section E: Foundation Trust Membership

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

Foundation Trust Membership ^*

Yes No

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-19? (both vaccinations) ^*

Yes No

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

Yes No

Have you a condition that makes you more likely to get infections? ^*

Yes No

Are you taking medicines that weakens your immune system? ^*

Yes No

Are you immunosuppressed? ^*

Yes No

Are you receiving treatment for blood and bone marrow cancer? ^*

Yes No

Are you pregnant? ^*

Yes No

Have you had an organ transplant? ^*

Yes No

Are you receiving cancer treatment? ^*

Yes No

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 ^*

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

Gender ^*

Male

Female

Non-binary

I do not wish to disclose this

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

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

I do not wish to disclose this information

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

Learning Disability/Difficulty

Sensory Impairment (hearing / sight)

Long-Term Health Condition

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

Lived experience of mental health

Other

Sexual Orientation

Please select which sexual orientation applies to you:

Heterosexual

Gay or lesbian

Bisexual

Other sexual orientation not listed (please state)

I do not wish to disclose

If Other, please state

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 2008 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.

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 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.

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.

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