Radio Chelsea and Westminster Application form

Title

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First Name

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Surname

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Date of Birth

Address

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Postcode

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Telephone

Must be a number greater than 0

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E-mail address

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What is your current employment / availabilty?

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What interests you about hospital radio

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Describe a situation where you have helped someone in need. (this may be as part of previous voluntary work or within your private life). What action did you take?

What was the situation?

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What was the outcome

What was your action and what was the outcome

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What might you bring to the station over and above voluntary duties?

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Please indicate if you have ever worked with any of the following

select as many as required

Children
The elderly
People with mental health problems
the physically or sensory impaired

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Have you ever volunteered before?

Yes (if yes, please complete the below)
No (if no, please scroll down to references)

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Name and address of previous Organisation / Charity

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Main Duties

what did you do at the organisation / charity

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From

To

Name and address of previous Organisation / Charity

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Main Duties

what did you do at the organisation / charity

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From

To

Please give details of two people who we may approach if called for interview and who are able to provide references relating to your experience and suitability to this post. The referees should be your two most recent employers (including voluntary work) including your current one and must hold positions of direct responsibility relative to you (friends and family may not be submitted as referees.) REFERENCE 1 :

First Name

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REFERENCE 1

Surname

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REFERENCE 1

Address

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REFERENCE 1

Telephone

Must be a number greater than 0

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REFERENCE 1

Relationship to you (e.g Line manager, work colleague etc.)

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REFERENCE 2:

First Name

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REFERENCE 2

Surname

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REFERENCE 2

Address

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REFERENCE 2

Telephone

Must be a number greater than 0

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REFERENCE 2

Relationship to you (e.g Line manager, work colleague etc.)

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Emergency contact details: - please give details in case of an emergency

Name

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Address

inc. postcode

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E-mail

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Telephone

landline and mobile

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Relationship to you

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Are you related to a member or officer within Chelsea and Westminster Hospital NHS foundation Trust ?

Yes
No

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Have you previously worked or volunteered within Chelsea and Westminster Hospital NHS foundation Trust

Yes
No

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Are you legally entitled to work in the UK

Yes
No

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REHABILITATION OF OFFENDERS ACT 1974 I confirm that to the best of my knowledge the details given are correct. I understand that the post applied for is NOT protected by the Rehabilitation of Ofenders Act 1974 and that I must disclose all information about all convictions (if any) in a Court of Law, no matter when they occurred. Due to the special nature of some posts, prospective volunteers will be subjected to a Criminal Record Bureau check.

ARE YOU CURRENTLY BOUND OVER OR HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE IN THE UK OR IN ANY OTHER COUNTRY?

Yes
No

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By completing the next section you you understand and agree to the below text

In accordance with the 1998 Data Protection Act it is agreed that CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST may hold and use personal information about me for placements reasons and to enable CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST to keep in touch with me. This information can be stored in both manual and/or computer form, including the data in section 2 of the Data Protection Act 1998. I understand that in order to be considered for placement as a volunteer I will be asked to produce evidence of identification, address, and status in the UK when applicable. I understand that my ID Badge is property of CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST and when I stop volunteering I have to surrender my ID Badge to the Volunteer Liaison Manager. I understand that in accordance with CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST policy, if I do not come into CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST to volunteer for longer than thirteen consecutive weeks, I will have to re-apply in order to join the volunteers’ team again. I declare that the information given on this form is true and complete. I understand that any false information may result in the withdrawal of any offer of voluntary role or my dismissal if accepted as a volunteer.

Yes, I agree

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Please confirm you agree to this by confirming your name

Full Name

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Confirm today's date