Application for Volunteer Positions About You Title First Name Surname Address Post Code Date Of Birth Home Tel No (req'd) Mobile Tel No (req'd) Email Address Emergency Contact Information Name Relationship Home Tel No (reqd) Mobile Tel No (reqd) Additional Needs Do you require any additional support because of a Disability? (please circle) Yes No If yes, please state the type of support you require Special Qualifications and Skills Please give any details of any qualifications or special skills that you think may be beneficial to you in your role as Volunteer at Apple FM (if applicable – if not, leave empty) Availability Please indicate your possible times available to help Apple FM (this can be amended) Days Available Monday Tuesday Wednesday Thursday AM PM Extra Information How did you first hear about Apple FM? 1 Friday Saturday Sunday References Please provide the details of two people who would be willing to supply a character reference (can be your current or recent employer or someone – but NOT family member) Reference One Reference Two Name Name Address Address Postcode Postcode Capacity known to you Capacity known to you Email address Email address Telephone No Telephone No Declaration To the best of my knowledge the details on this application form are true. I understand that any misrepresentation found in this application after my appointment may lead to the termination of the agreement. I understand that the information given by me on this application form will be processed in accordance with the Data Protection Act 1998. I understand that this post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (DBS) to check for any previous convictions. I authorise Apple FM's HR Director (or persons acting on their behalf) to act as intermediary between MPH HR Dept and myself in relation to my Volunteer application and the DBS & Reference collecting process. I also give my authorisation that Apple FM's HR Dept should be issued with copies of the replies that are received in response to reference requests. Signed Date When completed please send to: Alan Collins, HR Director, Apple FM, The Studio, Musgrove Park, Taunton. TA1 5DA For Office Use Only DBS Form Ref F01 Car Park Pass Required? Vol Conf Stat Signed Yes No ID Accepted: 1) If “Yes”, Car Reg No? 2) Photo Taken Passed to Vol Serv Polo Shirt Size Date Issued Vol Agmnt Signed Interview Date 3) Refs Received 1) Badge ID No Trainer Date Training Started 2 2) VOLUNTEER CONFIDENTIALITY STATEMENT Any matters of a confidential nature, including any particular information relating to the diagnosis and treatment of patients or individual staff records must under no circumstances be divulged or made available to any unauthorised person(s). It is important to service users to feel confident that information they give will not be passed on to anyone without their permission. It is equally important for service users to feel confident in giving us this information so we can deliver the best possible service. We ask all volunteers to sign a copy of the statement below to show they understand the need for confidentiality and agree to keep information confidential. • • • • I will respect the privacy of services users, other volunteers and staff and confer appropriately with those designated as my supervisors. I will use all information gained in the course of my service in a reasonable manner. I will not at any time use any photographic equipment on Musgrove Park Hospital premises, unless authorised to do so. I understand that misusing information will lead to the suspension or dismissal of my voluntary role. Name Signature Date 3