Section A: Personal Details

Last or Family Name ^*

Title ^*

Forenames ^*

Date of Birth ^*

Address ^*

Town ^*

Postcode ^*

Email address ^*

Use this for the DBS Check? ^*

Yes No

Telephone number (home or mobile) ^*

Section B: Emergency Contacts

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

Title ^*

First Name ^*

Last/Family Name ^*

Email address ^*

Address ^*

Telephone number (home or mobile) ^*

Relationship to you ^*

School Contact:

Title ^*

First Name ^*

Last/Family Name ^*

Email address ^*

Address ^*

Contact telephone ^*

Section C: Character References

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

Name ^*

Address ^*

Postcode ^*

Telephone Number ^*

Email address ^*

Relationship to you i.e. teacher, tutor, friend etc. ^*

Section D: Volunteering

Do you speak any other language? (please state)

Do you have any voluntary service experience? ^*

Yes No

Volunteering role examples: • Meet and Greet • Patient Surveys • Kindness Companion

Approximate hours per week you would be able to volunteer ^*

Days and times preferred? ^*

Chest size for Volunteer polo tops and shirts/blouses

A variety of sizes are available on request.

Polo top ^*

S M L XL XXL N/A

Mens shirts ^*

15 15.5 16 16.5 17 17.5 N/A

Womens blouses ^*

10 12 14 16 18 N/A

Section E: Foundation Trust Membership

Becoming a Trust volunteer automatically enrols you as a Foundation Trust Member.

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

Are you a foundation trust member? ^*

Yes No

Section F: Health Declaration

Are you in good health? ^*

Yes No

Are currently being treated by your GP? ^*

Yes No

Do you suffer from Epilepsy? ^*

Yes No

Do you suffer from Diabetes? ^*

Yes No

Have you been immunised against:

Tuberculosis ^*

Yes No

Hepatitis B ^*

Yes No

Rubella ^*

Yes No

Tetanus (up to date) ^*

Yes No

Polio ^*

Yes No

Covid ^*

Yes No

GP/Health Professional Authorisation

Name of GP ^*

Address ^*

Section G: 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 on a separate sheet of paper, which should be returned with this application form.

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

The NHS and the East Kent Hospitals NHS Trust are anxious to ensure that they do not discriminate against any person on the grounds of sex, race, ethnic origin or disability. Similar information is being collected about all staff members and patients. This information is used for statistical monitoring only and will not be shared with any third party without your express permission.

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

Do you consider yourself to have a disability or long-term health condition?

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.

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 in Respect of Confidentiality

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.

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 2018.

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.

Youth Volunteer Form