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Volunteer application form

Thank you so much for your interest in applying to become a volunteer. To apply, please complete the form below and one of the team will be in touch.
If you have any questions or would like to discuss your application over the telephone, please call 01298 816 990.

We understand that former hospice patients, clients, and carers, may wish to support Blythe House Hospice (BHH) by volunteering. We strongly recommend a gap of at least 12 months between the date of discharge from all Blythe House Hospice services, or after experiencing a bereavement, and applying for a hospice-based role. A gap of six months is recommended before considering a volunteer role based in one of our shops.

Volunteer Form

Personal Details

Title

First Name

Last Name

Known As

Preferred pronouns

Email

Date of Birth

Address

Address Line 1

Address Line 2

Town

County

Postcode

Country

Phone

Mobile

Full Driving Licence

Yes

No

Own Transport

Yes

No

Willing to transport patients

Yes

No

Who would you like us to contact in the case of emergency?

Name of your emergency contact

Relationship to you

Address

Address Line 1

Address Line 2

Town

County

Postcode

Country

Contact tel no

Have you accessed Blythe House Hospice Services in the last 12 months?

Yes

No

Have you experienced the death of someone close to you in the last 12 months?

Yes

No

Skills & Experience

Are you currently employed:

Yes

No

Student

Retired

Volunteering

Other

Please let us know of any interests, experience and skills that you have that may be relevant to the volunteer role

Volunteer role(s) interested in

Which service/area are you most interested in supporting?

Administrative

Driver

Fundraising

Patient Facing Volunteer (Hospice or Community based)

Trustee

Retail

Gardening

Preferred retail location (if applicable):

Bakewell

Buxton

Chapel

Whaley Bridge

New Mills

Matlock

Ecommerce

About You

How did you hear about volunteering for Blythe House Hospice

Internet / Social Media

Word Of Mouth

Friend

Staff Member

Poster / Flyer Radio

Already Connected To Blythe House

Press

Other

Are there any reasonable adjustments that you would need for the role?

Yes

No

If yes please elaborate

References

Please provide details of two people who can give us a reference. Email contact details are preferred for referees if possible - thank you! We ask for:

One professional or business referee - this could be a current or previous employer, line manager, colleague, tutor, teacher, or someone who has worked with you in a formal capacity (for example, a Job Centre work coach, support worker, or volunteer coordinator from another organisation).
One personal referee - someone who knows you well but is not a family member, partner, or relative.

Guidelines for both referees:

Should have known you for at least two years. If you are currently in education or employment and a referee has known you for the duration of that role but for less than two years, please tell us, and we will consider it.
Should not be a family member, partner, or relative
Should not be a current Blythe House Hospice volunteer or staff member
Must not live at the same address as you
Preferably should not be known to each other

If you are unable to provide a professional or business referee, please let us know and we will discuss possible alternatives.

Reference 1

Full name of your first referee

Business / Personal

Business

Personal

How long have you known this person and in what capacity?

Email

Telephone

Reference 2

Full name of your second referee

Business / Personal

Business

Personal

How long have you known this person and in what capacity?

Email

Telephone

Disclaimer

I confirm I have the right to work as a volunteer in the United Kingdom:

Yes

No

Do you have any criminal convictions ? ( NB - Roles exempt from the Rehabilitation of Offenders Act - and all offences must be declared)

Yes

No

If Yes please explain

Data Protection

It will only be used to send you information from Blythe House and will not be shared to a third party for any marketing purposes.
Your personal data will be held securely.
If you wish to update your contact preferences at any time, please contact the Volunteer Team.
Our system will record your data and will be treated as confidential. It may be used for internal review and, if requested, to notify you about updates to the website. Blythe House Hospice will treat personal information sent as confidential. No personal information, including email addresses, will be shared with any third party for the purpose of marketing.

Confidentiality

All patients, clients, their families and carers have the right to expect that Blythe House staff and volunteers will respect their confidentiality.
All volunteers are required to treat all they know or learn about a client as strictly confidential. Confidentiality can be a difficult area and volunteers are encouraged to discuss any problems about confidentiality with the Volunteer Team or an appropriate senior staff member.
By signing this form you are confirming that you understand that during the course of your volunteering you will treat as confidential all information concerning current or former patients, clients, their families and carers and you undertake not to divulge any such information and if any doubt you will refer the matter to the appropriate senior staff member. Failure to respect confidentiality may result in you being asked to step down from your volunteer role(s).

Diversity Information

Please provide us with the following information to assist our efforts in monitoring the diversity in our volunteer team. By completing this form you are providing Blythe House Hospicecare with your consent to use your information for this purpose. Completing this form does not constitute any part of the recruitment and selection process.

Are You

Male

Female

Other

Prefer not to say

Age

Under 18

18 – 24

25 – 34

35 – 44

45 – 54

55 – 64

65 – 74

75+

Do you identify as someone living with a recognised disability as outlined in the Disability Discrimination Act?

Yes

No

Do not wish to disclose

Ethnic Group

Asian or Asian British – Bangladeshi

Asian or Asian British – or any other Asian background

Asian or Asian British - Pakistani

Asian or Asian British – Indian

Black or Black British – African

Black or Black British - Caribbean

Black or Black British – Other

Chinese

Mixed White and Asian

Mixed White and Black African

Mixed White and Black Caribbean

Mixed – any other mixed background

White - British

White – Irish

White any other white background

Blythe House Hospice

Eccles Fold, Chapel-en-le-Frith, High Peak, Derbyshire, SK23 9TJ

Registered name: High Peak Hospicecare.
Registered Charity No. 1031192.
Registered Company No. 2880281.

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