Volunteering Application Form

Name

First Last

Known as

Sex*

Address*

Street Address City County Post code Country

Are you over 18?*

If no, please provide your date of birth*

Home Phone

Mobile Number*

Email*

Areas of interest

Where would you like to volunteer? Please see our volunteering opportunities list.

Option 1	Option 2	Option 3

Please indicate your availability to work mornings*

Leave blank if you are unavailable

Please indicate your availability to work afternoons*

Leave blank if you are unavailable

Please indicate your availability to work evenings*

Leave blank if you are unavailable

Where did you hear about volunteering for St Luke's Hospice?*

If other, please let us know here:*

Person to notify in case of emergency

Name*

First Last

Address*

Street Address City County / State / Region Post code Country

Contact number*

Relationship to you*

Experience, skills and qualifications

Voluntary or employment experience – please give brief details*

Other experience and skills – please give details of any other experiences, skills and characteristics that you are happy to continue to use for our Hospice*

To help us, would you please tell us why you chose to volunteer for St. Luke’s?

Bereavement: Have you been bereaved of a close family member or friend in the past 12 months? If yes, please give details.

References

Please give details of two referees over the age of 18 years, who have known you for more than two years, and are not related to you.

Name

First Last

Address

Street Address City County / State / Region Post code

Phone

Email

Relationship

Name

First Last

Address

Street Address City County / State / Region Post code

Phone

Email

Relationship

Criminal Convictions

Any information you supply on this form is confidential and will only be used in respect of your voluntary placement in line with the Data Protection Act 1998. By submitting this application form you consent to St Luke’s Hospice using this information for this purpose. Any information given will be considered only in relation to applications for positions covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants are not entitled to withhold any information about criminal convictions, however long ago these occurred. Failure to disclose such convictions could result in being released from a volunteer role.

Have you ever received a criminal conviction?*

If yes, please give details*

Mailing List

By submitting this application form you will be indicating that you consent to receiving mailings from St Luke’s Hospice unless you have indicated an objection to receiving such messages by ticking this box:

Confirmation*

I confirm that the information supplied is accurate and that I have not knowingly withheld any information which is relevant to the application. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may preclude me from volunteering for St Luke’s.

Name*

First Last

Date of application*

Signature*

St Luke’s Hospice welcomes volunteers without regard to race, colour, religion, national origin, gender, sexual preference, age, or disability.

Areas of interest

Person to notify in case of emergency

Experience, skills and qualifications

References

Criminal Convictions

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