VOLUNTEER APPLICATION FORM

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1 Thank you for your enquiry about becoming a volunteer with Hospice North Shore. Volunteers are an important and integral part of the Hospice North Shore team, and there are a wide variety of ways in which your gift of time and life experience may benefit the patients and the Hospice organisation. As well as the application form, we have enclosed a 2017 timetable for the monthly Introduction/ Orientation to Hospice North Shore sessions. Please note that it is a requirement of the Hospice North Shore Volunteer policy that all new volunteers attend one of these sessions. It is important that you book a date to attend one of these sessions as the available spaces fill quickly. Please complete and return your application form and the tear-off slip at the bottom of the Intro / Orientation form telling us which date suits you to attend. Once we receive your completed application form, we will contact you to arrange an interview appointment. Any questions you may have can be answered then. Please note Hospice North Shore conducts a vetting check on all Volunteer applicants aged 17 years and older, either through the New Zealand Police or the Ministry of Justice. The type of check conducted is dependent on which Volunteer role you are interested in. For this we need proof of your identity. When we contact you to arrange an interview we will explain what types of identification documents you can use and we will ask you to bring your identity documents with you. Once again, thank you for your enquiry and we look forward to meeting with you. Regards Volunteer Services volunteerinfo@hospicenorthshore.org.nz Phone:

2 Introduction / Orientation to Hospice North Shore Timetable 2017 Month: Date: Morning: Evening sessions: February Friday 10th 9.30am am March Friday 3rd 9.30am am March Friday 24th 9.30am am April Friday 7th 9.30am am May Wednesday 10th 5-7pm June Friday 9th 9.30am am July Friday 14th 9.30am am August Friday 11th 9.30am am September Wednesday 6th 5 7pm October Friday 6th 9.30am am November Wednesday 8th 5 7pm December Friday 8th 9.30am am All training will be held in the Kea Room at Hospice North Shore, 7 Shea Terrace, Takapuna. Please note that car parking on site is limited. Street parking has a two hour limit; parking is also available at the Hospital, charges apply. Please tear off this coupon and return to Volunteer Services, at the address on the letterhead. I will be attending an orientation session on:. (Please write the date and time of the session you want to attend) Your Name:. Your Address:. Contact No:.. Mobile Phone No:

3 PERSONAL DETAILS Date: / / Full Name TITLE (Mr / Mrs / Miss / Other) FIRST NAME & SURNAME: Preferred Name This is the name that will be on your name badge: Address Address Home Phone No. Work Phone No. Date of Birth Occupation Mobile No. EMERGENCY CONTACT (TO BE USED ONLY IN CASE OF ACCIDENT, SUDDEN ILLNESS OR CIVIL EMERGENCY) THIS INFORMATION WILL BE HELD ON YOUR PERSONAL FILE FOR EMERGENCY USE ONLY. Name Next of Kin Relationship Phone (Day) Phone (Evening) Mobile 3

4 REFERENCES Please give the contact details of two referees who are not members of your own family, and who have known you for at least 2 years and who are in a position to comment on your reliability, trustworthiness and suitability for your volunteer role. This might be an employer, colleague, teacher or neighbour, etc. Please check with all referees that they are willing to act as a referee. REFEREE ONE REFEREE TWO Name Name Telephone Telephone In what capacity do you know Referee One? In what capacity do you know Referee Two? AREAS OF INTEREST It is our custom to offer Volunteers positions that suit their availability, skills and interests. All new Volunteers will be interviewed by a member of the Volunteer Services Team. Placement will be based on the Volunteer s skills, experience, interests and availability. However if the vacancies do not fit a Volunteer s convenience or skills, it may not be possible to place a volunteer in a particular area of volunteering immediately. Whenever possible appropriate alternative roles will be offered until a vacancy occurs. Please indicate on the last page the area in which you prefer to volunteer, and are able to commit to a regular roster, either weekly or fortnightly. SPECIFIC SKILLS AND TRAINING Please list any specific skills, training, interests or work experience that you have, that may influence the area where you are assigned as a Hospice Volunteer including previous work experience: 4

5 CRIMINAL RECORD DISCLOSURE Have you been convicted of a criminal offence (within the last 7 years) or are you awaiting a criminal court hearing or undergoing disciplinary action? (please tick box) If yes, please describe: Do you give consent for Vetting/Police Check? Any information given will be confidential and will not necessarily disqualify Yes No Volunteers from Voluntary work but will be considered when assessing your suitability. Having a criminal record will not automatically bar you from volunteering with us, depending on the circumstances and discussion with you). CONFLICT OF INTEREST DECLARATION VOLUNTEER APPLICATION FORM DO YOU HAVE A STALL OR BUSINESS SELLING SECOND HAND GOODS? Any staff or volunteers with a conflict of interest from their own business need to agree purchasing boundaries with their manager to safeguard both parties. If your circumstances change and you do start selling second hand goods you must inform your manager. HEALTH DECLARATION Yes Yes No No Do you have a health condition (physical or mental), or are you on any medication which may affect your ability to carry out your volunteer role at Hospice North Shore? (please tick) Yes No If Yes, please give brief details here: To ensure your safety and that of others, we are not able to offer you a start date until we are satisfied that you are medically fit to undertake the Role. We may require a Medical Certificate from your GP confirming you are able to carry out the role. If there are changes to your health that may affect your ability to volunteer, you are obliged to inform Hospice immediately. GENERAL DECLARATION I confirm that all details supplied on this form are true and complete to the best of my knowledge and I recognise that failure to declare any relevant information or to supply the details required may result in my volunteer role with Hospice being discontinued. I understand that the information on this form will be held securely on the Hospice database and on paper in the Volunteer Services Department. Name: Signature: Date: / / 5

6 7 Shea Terrace, Takapuna, Auckland 0622, New Zealand AREAS OF POSSIBLE VOLUNTEER INVOLVEMENT We are looking for people who can commit to volunteering for a four hour shift on a regular basis (either weekly or fortnightly) in the following areas: Retail Shops Albany Birkenhead Birkenhead Bookshop Ellice Road (Glenfield) Shop & Clearance Centre Milford Milford Home Store Browns Bay Devonport Takapuna Link Drive (Wairau Park) At Hospice Admin / Office tasks (Computer skills required) Assisting in Kitchen Gardening Handyman / Maintenance / Vehicle Reception / Front Desk Patient Contact Roles (Please note: There is a requirement for all new volunteers in these roles to attend a one day Palliative Care Course) Community Home Visiting Complimentary Therapies (Massage& Reiki) * Please see website for qualifications required Day Group Driving Patients to appointments (You will need to be willing to transport patients to medical appointments in your private car) Life Review Event & Fundraising Activities In addition to your regular volunteering there are opportunities to assist our Fundraising Team with a range of fundraising event administration and activities. Other Are there any other skills that you are willing to offer to Hospice North Shore? 6