Volunteer application form - Hospice based

Basic details
First Name*
Preferred Name
Surname*
Address*
Postcode
Telephone
Home Mobile
Email
Occupation
What languages do you speak?
Date of birth
MM slash DD slash YYYY
What has attracted you to volunteering for Cranford Hospice?
What personal or professional qualities and experiences have you had that will assist you as a volunteer?
Do you have previous volunteering experience? Please describe this.
How did you find out about volunteering opportunities at hospice?
Have you experienced a close bereavement in the last 12 months?
- Yes
- No

PERSONAL HISTORY
Have you ever been convicted of a criminal offence in the last 10 years?*
- Yes
- No
Do you have a criminal conviction, or have charges pending in New Zealand or overseas jurisdiction?*
- Yes
- No
(It is important to note that having a criminal history will not necessarily exclude you from volunteering)
Please provide the names and contact details of two referee who will be happy to support your application to become a volunteer. (Your referee should not be a close relative)
*
Name Phone number Relationship to you

Medical Emergency Contact
Contact Name
Relationship
Phone
Home Work Mobile
Health Declaration
I have had an injury or medical condition or disability which:
- May be aggravated by my working at the volunteering job for which I am applying.
- May reduce my ability to carry out efficiently all the duties required of me.
Note: injury or medical condition or disability includes any condition caused by gradual process, accident, disease or infection, such as but not limited to noise induced hearing loss, back problems, musculoskeletal problems, occupational overuse syndrome (repetitive strain injury), alcohol and/or drug addiction/dependence, chemical sensitivity in the form of dermatitis, allergies or respiratory problems.
Injury*
- Yes
- No
Please give details of any such injury, medical condition or disability:*
I am taking medication and/or having treatment which has side effects, e.g. drowsiness, slowed reaction times, which may reduce my ability to carry out safely and efficiently all the duties required of me.
Hidden
Medication*
- Yes
- No
The medication or treatment is:*

Confidentiality, Personal Information and Privacy Agreement
- I agree to my name and phone number being used within Cranford Hospice
- I understand that I will be required to attend training courses
- The personal information contained in this form will be held by and remain confidential to Cranford Hospice, Under the Privacy Act 1993, you have the right (with certain exceptions) to request access to, and correction of, any personal information held by us.
- I declare that all the information provided by me in support of my application is correct. I acknowledge that if I have provided incorrect or misleading information or have omitted information of significance, I may be disqualified from becoming a volunteer, or if appointed, be liable to be dismissed.
Please ensure you have completed all sections of this form before signing this declaration.
I declare that to the best of my knowledge the answers provided in this application form and any other information provided to the Cranford Hospice in support of my application is correct and I understand that if any false or deliberately misleading information is given, or any material suppressed, I will not be accepted, or, my volunteer engagement may be terminated.
Full name*
Date*
MM slash DD slash YYYY
If you have any questions, please contact the Volunteer Coordinator Amanda Aitken (06) 878 7047

Volunteer application form – Hospice based

Name	Phone number	Relationship to you

Home	Work	Mobile