VOLUNTEER APPLICATION FORM
(All information will be treated in confidence)
SURNAME: .............................……... FORENAME: .............................……... MR/MRS/MISS/MS
ADDRESS: ..................................................................................………..............................................
TELEPHONE
HOME: ................................…..
BUSINESS: .…................................
MOBILE: ..........................……..
E-MAIL: .........…..............................
The minimum age to volunteer here is 18 Years Old. Are you over 18 Years?
Yes
OCCUPATION: .................................................................…….
QUALIFICATIONS (if any): ....................................................................................................……….
CAR OWNER
DRIVER 
MAKE/MODEL: ............... REG. NO.: ........................……
Do you have any medical condition/illness that might affect your work as a volunteer? If yes, please
give details: ……………………………………………………………………………..………………
Are you engaged in other voluntary work? Please give details:.................................……..…...............
Have you done voluntary work in the past? Please give details:........................................….……….....
How did you hear about the Hospice Volunteers? ....................................................................………
Why have you chosen to seek a volunteering opportunity with St Francis Hospice?...........…...………
....................................................................................................................................................………
Have you any particular hobbies or skills that you hope to use in your volunteering? ………………
....................................................................................................................................................………
Have you had any experience, personal or otherwise, with a terminal illness? Have you had any
experience of persons who have been bereaved? Have you suffered a recent loss? If yes to any of these
questions, please let us know what your experience has been and how long ago it was:
...........................................................................................................................................………..p.t.o.
Sunday
Monday
AVAILABILITY
Tuesday Wednesday
Thursday
Friday
Saturday
Morning
Afternoon
Evening
Hospice Preference
St Francis Hospice Raheny
□
St Francis Hospice Blanchardstown
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REFEREES (All Applicants)
You will be aware that as we work with vulnerable people, we have to be very vigilant in all our
recruitment activities - be they for paid staff or volunteers. We would therefore ask you to provide
us with names of two referees who know you well whom we can contact in advance of meeting with
you (from non-relatives and from separate sources e.g. employment, previous volunteering or from
a person of standing within the community).
(1)
Name: ...........................................................
Address: ...........................................................................................................................
Telephone No.: .................................... Position held: .....................……....…...............
(2)
Name: ............................................................
Address: ...........................................................................................................................
Telephone No.: .................................... Position held: ...........................…….….............
Please note your referees will be contacted before we meet with you.
Any other comments you would like to add: .....................................................................….........
.......................................................................................................................................................
GARDA VETTING FORM: Please complete the Garda Vetting form also and return with your
completed Application Form. We will not process Garda Vetting until we have met with you
regarding a suitable role.
I declare that the information I have given is, to the best of my knowledge, true and accurate.
Signed: ..................................................
Please return completed forms to:
Date: .......................................................….
Brenda Farrelly, Co-Ordinator Volunteer Services
St. Francis Hospice
Station Road, Raheny, Dublin 5
VOLUNTEER POSITIONS
Please tick positions for which you have skills or are interested in
Description and shift details for each Role on St Francis Hospice website
Garda vetting carried out (prior commencement) for all volunteer positions
HOME CARE
Reception Desks
Visits
Library / Education Department
Administration
DAY CARE
Fundraising/Finance Department
Driving
Gardening
Hospitality Volunteer
Bus Escorts
Flowers and plants (inside)
Musician
Administration(Computer skills)
OUT PATIENTS CLINIC
Driving
Singer
Hospitality Volunteer
Bus Escorts
Bookclub
BEREAVEMENT & SOCIAL WORK
Bereavement Support
Hospitality-Bereavement
Info Evenings
IN PATIENT UNIT
Hospitality Volunteer – Day
Hospitality Volunteer - Night
Coffee Shop
Positions requiring professional qualification and experience:
Complementary Therapy:
Reflexology
Pottery
Aroma Therapy
Hairdressing
Massage
Art &/or Crafts
Hand Care (Red Cross Course)
Relaxation
Beauty Care
Dog Visits (PEATA or Irish
Therapy Dogs trained)
GUIDE TO COMPLETING GARDA VETTING APPLICATION FORM

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Please use BLOCK CAPITALS and black pen when completing the Garda Vetting Form.
Please insert N/A if details are not applicable. The form must be fully completed – do not ignore any
section
Writing must be clear and legible
It will not be possible to process incomplete or incorrect application forms
Completed form must be returned with photocopy of driving licence or page of passport with
photo. Completed Garda Vetting form to be returned with completed volunteer application form to
Co-ordinator Volunteer Services, St Francis Hospice.
1.
Surname:
Enter current surname (i.e. second/family name)
2.
Previous Name:
Insert your previous name (i.e. name before marriage or previous name if
you have ever changed your name)
3.
Forename:
Insert your first name.
4.
Alias:
Please insert if you are known by any name other than the name on your
Birth Certificate.
5.
Date of Birth:
Insert Date of Birth (dd/mm/yy, e.g. 10th July 1960 = 10/07/60)
6.
Place/City of Origin: Insert Town/City and if not in Ireland, Country of birth also.
7.
Have you ever changed your name: Please tick box Yes or No (i.e. if changed by deed pole)
8.
If yes please state former name:
Insert former first names and/or surnames
9.
Please state all addresses from year of birth to present date: It is important that this section is
completed in BLOCK CAPITALS and in date order from birth to present. Do not leave any dates
unaccounted for. Please see example below;
House No
203
106
N/A
Street
SWORDS ROAD
KINGS ROAD
COMMONS ROAD
Town
WHITEHALL
WIMBLEDON
ARDFERT
County
DUBLIN
LONDON
KERRY
Post Code
D9
WC1 2H
N/A
Country
IRELAND
ENGLAND
IRELAND
Year From
1960
1971
1990
Year To
1971
1990
Present
10.
Have you ever been convicted of an offence in the Republic of Ireland or elsewhere?
Please tick box No or Yes (Yes for any convictions or prosecutions, successful or not, pending or
completed) If Yes, please insert details in table provided in BLOCK CAPITALS.
11.
Declaration of applicant
- In the section that says” I the undersigned who have applied to work as …….hereby’ complete
with the role VOLUNTEER
- The applicant must read the Declaration carefully, sign and date it. The name should be
printed in BLOCK CAPITALS underneath the signature. (signature must agree with
Surname & Forename as completed on front page of form – signature B Farrelly not OK,
must be Brenda Farrelly)
- By signing this declaration you give permission to An Garda Síochána to release your
personal information directly to the Authorised Signatory, who is authorised to receive it
on behalf of the hospice. This Garda Vetting is non transferrable to any other organization.
NOTE TO APPLICANT
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


The Application Form must be completed in full using BLOCK CAPITALS
(Please state N/A if details are not applicable)
Writing must be clear and legible.
Return the completed form to St. Francis Hospice, Station Rd, Raheny, Dublin 5.
Do not send this form to the Garda Central Vetting Unit or to any Garda Station.
To be completed by applicant
SURNAME:
FORENAME:
PREVIOUS NAME (if any):
ALIAS:
DATE OF BIRTH: (dd/mm/yy)
PLACE / CITY OF ORIGIN:
HAVE YOU EVER CHANGED YOUR NAME?
Yes
No
IF YES PLEASE STATE FORMER NAME:
Please state all address from year of birth to present date:
House
No.
Street
Town
County
Post
Code
Country
Year from
Year to
Please continue on next page
Have you ever been convicted of an offence in the Republic of Ireland or elsewhere?
No
Yes
Please provide details
____________________________________________________________________________________________________________
DATE
COURT
OFFENCE
COURT OUTCOME
DECLARATION of Applicant
I, the undersigned who have applied to work as a* __________________________ hereby authorise An
Garda Síochána to furnish to ST. FRANCIS HOSPICE a statement that there are no convictions
against me in the Republic of Ireland or elsewhere, or a statement of convictions and / or prosecutions,
successful or not, pending or completed, in the State or elsewhere as the case may be subject to the
administrative filter implemented by the Minister for Justice and Equality on 31st March 2014.
Signature of Applicant:
_____________________________________
Date:
________________________
Please print also
*(
)*this field is mandatory
To be completed by St. Francis Hospice
Line Manager/Contact Person: ____________________________________
Authorised Signatory:
Please print also
*(
Location: ___________________
_____________________________________ (St. Francis Hospice)
) *this field is mandatory
Authorised Signatory Registration Number:
________________
Date: _________________
To be completed by the Garda Central Vetting Unit
Checks were carried out by this office in accordance with current Garda Vetting policy and based on the information supplied in this application
form. The results are indicated below:
No convictions
Convictions
Prosecutions are pending
NOTE:
Checks were carried out by this office based on the information supplied.
The convictions may apply to the subject of your enquiry.
Please verify information disclosed with the applicant.
G.C.V.U.
Signed:
Member IC