Volunteer Application Form - St Wilfrids Hospice Eastbourne

Volunteer Application Form
Personal information
First/preferred name:
Post code:
E-mail address:
Daytime phone number:
Evening phone number:
Mobile phone number:
Date of birth (optional):
Do you have any medical conditions that may affect the type of voluntary work that you do?
If yes, please give details
Emergency contact: Name
How do you know about St Wilfrid’s Hospice?
Tel no:
Why do you want to volunteer with us?
References (Please give details of two relevant referees. Referees cannot be related to you.)
Tel no:
Tel no:
Data Protection
Information from this application will be used in accordance with the Data Protection Act 1998.
If you become a volunteer at St Wilfrid’s Hospice require you may require police clearance via the
Disclosure and Barring Service (DBS). Volunteers who fail to disclose a conviction during their time here
may have their position terminated.
I acknowledge that a voluntary position, if offered, will be subject to satisfactory references and DBS
clearance (if applicable).
I understand that I shall receive no monetary payment or goods in exchange for volunteering. I will l
observe strict confidentiality as to the affairs of St Wilfrid's Hospice.
I declare that the information given on this form is correct. I understand that if offered a voluntary role,
providing false or misleading information or deliberate omissions will be regarded as grounds for
I declare that the information I have given is to the best of my knowledge true and complete.
Signed: ………………………………………………………………….…………………………………
Date: ………………………….……………………..…………….
Thank you for completing this application form. Please return it to:
Voluntary Services
St Wilfrid’s Hospice
1 Broadwater Way
BN22 9PZ
Tel no: 01323 434200 Email: vsm@stwhospice.org
Alternatively, you can return the form to one of our shops.
St Wilfrid’s Hospice handles all personal data in full compliance with the Data Protection Act (1998). We do not share any
information with third parties and do not hold sensitive information. If you do not wish to be on our database of supporters,
please email hospice@stwhospice.org or call 01323 434200.
Equality and Diversity Monitoring Form
St Wilfrid’s Hospice aims to provide equal opportunities and fair treatment for all volunteers. The information below
is anonymous. It will be detached from your application form and will not be stored with any identifying information
about you. All details are held in accordance with the Data Protection Act 1998.
We would like you to complete this form in order to help us understand who we are reaching and to better serve
everyone in our community. The information will be used to provide an overall profile analysis of our volunteer base.
Please state what you consider your ethnic origin to be. Ethnicity is distinct from nationality and the categories
below are based on the 2001 Census in alphabetical order.
□ Indian
□ Pakistani
□ Bangladeshi
□ Any other Asian background
(please write in)
□ Caribbean
□ African
□ Any other Black background
(please write in)
□ White and Black Caribbean
□ White and Black African
□ White and Asian
□ Any other mixed background
(please write in
□ English
□ Irish
□ Scottish
□ Welsh
□ Any other White background
(please write in)
Age: ______________________
Chinese or other ethnic group
□ Chinese
□ Any other Ethnic group
(please write in
□ Rather not say
□ Rather not say
The Disability Discrimination Act 1995 (DDA) defines a person as disabled if they have a physical or mental
impairment which has a substantial and long term (i.e. has lasted or is expected to last at least 12 months) adverse
effect on one’s ability to carry out normal day-to-day activities. This definition includes conditions such as cancer,
HIV, mental illness and learning disabilities.
Do you consider yourself to have a disability according to the above definition?
□ Yes □ No
□ Male
□ Female
□ Rather not say
□ Rather not say
Which group below do you most identify with?
□ No religion
□ Baha’i
□ Christian
□ Hindu
□ Jewish
□ Muslim
□ Other (please write in)
□ Rather not say
Sexual orientation
How would you describe your sexual orientation?
□ Bisexual
□ Gay man
□ Lesbian
□ Other
Thank you for completing this form.
Transgender □
Transgender □
Female to Male
Male to Female
□ Buddhist
□ Jain
□ Sikh
□ Heterosexual or ‘straight’
□ Rather not say