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Registered
Charity No. 279077
CONFIDENTIAL
APPLICATION TO BECOME A VOLUNTEER
With Mid-Downs Radio
PLEASE PRINT YOUR DETAILS ON THIS FORM
Title:
First Name:
..
..
. Surname:
.
..
Address:
.
Postcode:
..
..
Contact
Details: Home Telephone:
Email :
Date of Birth:
How did you hear about us?
NEXT OF KIN for use in emergency
only
Name:
Relationship:
Address:
.
.Postcode:
..
Telephone: Daytime:
Evening:
CURRENT EMPLOYER
Name
and address:
..
Position
held:
.
Brief
details on any previous employment over the past five years:
YOUR AVAILABILITY we would prefer a
regular time each week.
Days:
Times:
Why
have you chosen to apply to Mid-Downs Radio?
REFEREES: Please provide details of two people to whom we
may write for a reference.
Referees should not be family members.
If you are currently employed or have
worked in the past five years please give your employer
as
one of your referees.
1) Name:
Relationship:
..
.
Address:
.
.
.
,.
Postcode:
..
Telephone:
2) Name:
Relationship:
..
.
Address:
.
.
.
,.
Postcode:
..
Telephone:
Have you ever been convicted,
cautioned or bound over in relation to a criminal offence? No / Yes
If yes, please give details:
.
Rehabilitation of Offenders Act 1974 (Exemptions Order
1975).
In
order to protect the public, the position for which you are applying is exempt
from Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exemptions Order
1975). This means that you are not entitled to withhold information relating to
any convictions you may have had even those which, in other circumstances,
could be considered as spent.
You
should supply such information on a separate sheet attached to the application
form. This information will be treated as confidential and will not necessarily
prejudice your application.
Applicants
for posts with access to children or vulnerable adults are reminded that any
appointment will be subject to satisfactory search of police records. (DOH Circular HC(88)(9)).
Confidentiality
I
have been advised of the fact and duly understand it to be a condition of my
membership of Mid-Downs Radio that all information in respect of patients,
visitors or staff, which comes to my knowledge, directly or indirectly, through
the course of my placement shall be treated as confidential, and may not be
discussed with or disclosed to any person including the patient or patients
concerned. I understand that a breach of this condition of my voluntary
services would be regarded as gross misconduct and will result in disciplinary
action (which may, in an appropriate case, involve instant dismissal from the
charity).
Declaration and Signature
I
declare that the answers and statements given are complete and accurate to the
best of my knowledge.
Signature:
Date:
Please return this form to:
Membership
Secretary
The
Haywards
Heath
RH16
4EX
Enclosures should include:
1)
Completed
Application Form
2)
Tax Gift Aid Form
if applicable
3)
Sealed envelope
addressed to The Occupational Health Dept containing the form already in it
plus your completed Occupational Health Questionnaire.
4)
And maybe, if you
choose, a donation of £5 towards the administrative costs of your application.
Thank you!