Volunteer Application form
Date of interview Possible placement area
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photo
VSM / Site 2………………………………………
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Personal details
Surname Title
First name(s)
Address
Postcode
Home Tel No Mobile No
Email Address
Your current Place of Work/Study
Emergency Contact Details
Name:
Relationship:
Tel number of emergency contact:
Additional Information
How did you find out about us?
Do you have any volunteering experience or skills?
Please confirm when you are available:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning
Afternoon
Early
evening
CONFIDENTIALITY AND INFORMATION SECURITY
As a volunteer you are bound to respect the confidentiality of any information you may come
into contact with which identifies patients, staff and/or business information of the organisation.
You are required to ensure that any such information is safeguarded to maintain confidentiality
and is kept securely in accordance with the law such as the General Data Protection Regulation
(GDPR), which came into effect on 25 May 2018, the Data Protection Act 2018, the Freedom of
Information Act 2000 and the common law duty of confidence.
The common law duty of confidence requires that when confidential, personal or sensitive
information is given in confidence to Medway Community Healthcare employees (including
temporary staff, locums, students, volunteers etc.) it is not shared with anyone else unless the
patient gives his or her permission.
The GDPR and the Data Protection Act sets out how organisations should process or handle
personal data and provides people with rights regarding data held about them.
If you are found to have misused your rights of access to the computer information you have
been given access to, e.g. accessed patient files it may lead to your dismissal and you could
also be prosecuted under the terms of the Computer Misuse Act 1990.
I agree to contact my voluntary services manager if I believe that I have, or become aware of a
potential or actual breach of confidentiality.
I have read and understood the above and agree not to disclose any confidential information
that I may come in contact with, even after I complete my term of volunteer work with Medway
Community Healthcare.
Signed: …………………………………………… Date:………………………………….
DATA PROTECTION ACT 2018
The Data Protection Act 2018 sets out certain requirements for the protection of your personal
information against unauthorised use or disclosure.
If appointed, your personal information or data will be processed and held on computerised and
manual records. This information/ data may be used by Medway Community Healthcare for the
purpose of monitoring and compiling statistics as well as other reasons connected with your
appointment. By signing this section you will be deemed to be giving consent to Medway
Community Healthcare using and processing it.
I consent to the use of my personal information for these purposes and under the terms set out
above.
Signed: …………………………………………… Date:………………………………….
REHABILITATION OF OFFENDERS ACT
The voluntary work that you are applying for may involve direct contact with vulnerable adults or
children who are accessing our services. Therefore, your voluntary work is exempt from the
provisions of the Rehabilitation of Offenders Act, 1974. Applicants should not withhold
information about convictions or cautions, reprimands or warnings. Failure to disclose any such
information will disqualify you from becoming a volunteer, or dismissal if the discrepancy comes
to light at a later date. All volunteers are required to undergo a check by the Disclosure &
Barring Service
Have you ever been convicted of a criminal offence or received a caution, reprimand or
warning? Yes No
If yes, enter details (i.e. date, type of offence/sentence/fine imposed). Please note this would
not automatically exclude you from working as a volunteer, as we consider this information on a
case by case basis.
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DECLARATION:
I agree to abide by the policies, procedures and guidelines relating to volunteering with Medway
Community Healthcare and that I will attend all relevant training courses provided by Voluntary
Services.
I hereby declare that I will hold in the strictest confidence any personal information concerning
patients which may become known to me during the course of my duties as a volunteer and that
I will not divulge such information nor discuss it with my colleagues in any public place.
I understand that such confidential or personal information includes a patients diagnosis and
treatment and any other particulars relating to their condition. I also understand that any
disclosure of such confidential information by me will result in the termination of my duties as a
volunteer.
I have read and understand all of the above and certify that the information on this form is true
and complete. I agree that any deliberate omissions, falsification or misrepresentation in the
application form will be grounds for rejecting this application or subsequent dismissal if engaged
by Medway Community Healthcare as a volunteer.
Volunteer signature:…………………………………………….Date:…………………………
PARENTAL CONSENT – Parent/Guardian Permission
Parental/guardian permission must be sought by applicants aged between 16 and 18.
Parents/guardians must fully understand what the voluntary work entails, the time
commitments, where you will be based and how you will be supervised whilst volunteering.
Parent/guardian Signature:……………………………………. Date:…………………………
Print Name: ……………………………………………………………………………………….
References
Please give details of two people willing to provide a character reference. Personal references
from family members are not acceptable.
Referee 1
Title Mr/Mrs/Miss/Dr other:
Name
Job Title
Address
Postcode
Telephone
Email address
Relationship (i.e.
teacher)
Referee 2
Title Mr/Mrs/Miss/Dr other:
Name
Job Title
Address
Postcode
Telephone
Email address
Relationship (i.e.
teacher)
For office use
References requested: …...../….…/.….… Rec 1: …...../….…/.….… Rec 2: …...../….…/.….…
DBS Form Completed: …...../….…/.….… Disclosure no: ….………..………..
DBS Form Ref: .…………………… Date Rec: …...../….…/.….…
Proof of address/ID seen/verified: …………………………………………………………………………………
ID Badge requested: …...../….…/.….… Rec: …...../….…/.….… No: ……………………
Car Driver Docs completed: …...../….…/.….… Info pack issued/signed: …...../….…/.….…
Task specification issued/signed: …...../….…/.….… Risk assessment issued/ signed: …...../….…/.….…
Start date: …...../….…/.….… Data-base entry: …...../….…/.….…
