Buddy Volunteer Application Form
Personal Information
Title
First Name
Middle Name
Last Name
Known As
Address
Town
County
Postcode
Date of Birth
Home Phone
Mobile Phone
Work Phone
Email Address
Feedback
Where did you hear about volunteering for Chestnut Tree House?
Availability
Which group are you available to carry out your volunteering? (Please indicate)
(NB: 15+ and 18+ denotes minimum age required to carry out role. 1:1 days and times to be arranged with parents / carers)
Saturday Youth Group (15+)
1:1 Buddy (18+)
Interests
Tell us what interest and activities you like doing. (Please indicate)
Arts & Crafts
Cooking
Singing
Bowling
Make-up and Pampering
Sports
Cinema
Music
Swimming
Zoo
Any other interests (please give details):
Skills, Qualifications and Hobbies
Summarise skills and qualifications you have acquired from employment, previous volunteering, or through
other activities, including hobbies or sports.
Previous Volunteer Experience
Summarise any previous volunteering experience you have.
Supporting Statement
Please use the space provided to say why you would like to be a Volunteer Buddy at Chestnut Tree House
and describe what experience, skills or personal qualities you feel you would bring to the role. Please also
include what you hope to gain from volunteering with Chestnut Tree House.
Driving Licence
Do you hold a clean, current driving licence?
Yes
No
If No, please give details:
Are you a car owner?
Yes
No
Do you have access to a car to use for voluntary work purposes?
Yes
No
Please give details:
References
Please provide the details of two people we can write to for a personal reference (not family members).
Title
First Name
Last Name
Address
Town
County
Postcode
Email
Title
First Name
Last Name
Address
Town
County
Postcode
Email
Emergency Contacts
Please provide the details of two people we can contact in case of emergency.
Title
First Name
Last Name
Home Phone
Mobile Phone
Work Phone
Relationship to you
Lives at same address
Title
Yes /
No
First Name
Last Name
Home Phone
Mobile Phone
Work Phone
Relationship to you
Lives at same address
Yes /
No
Data Protection
I agree to your holding and processing, electronically and by paper records, personal data and information
about me. I understand that this information is collected for the purposes of managing and administering your
staff and volunteers, if necessary for your business operations and/or compliance with applicable laws and
regulations. I also consent to the storage, transfer and processing by you of such data.
I understand that the records you hold and process may include, personal details (including the medical
questionnaire) and that such information and data is held securely within the Hospice records whilst I am
undertaking volunteer work and for 6 years after having ceased this volunteer duty at which time the records
will be destroyed. Personal Data and processing is as defined by the Data Protection Act 1998. I agree to
adhere to the Data Protection Policy of the Hospice.
Confidentiality
I understand everything that I hear or learn in the course of my duty as a volunteer at Chestnut Tree House /
St Barnabas House must be treated in the strictest confidence and should be considered as confidential
unless I am specifically told otherwise. This must include information regarding individual patients, families of
patients, staff, donors, supporters, colleagues and the activities of the hospice.
By confidential I understand that I must not share this type of information with anyone outside of the hospice
even families and friends.
I agree that my duty to confidentiality continues indefinitely even after I have stopped my volunteering duties
at the hospice.
Our Policy
St Barnabas Hospices use the Disclosure and Barring Service (DBS) to assess volunteers’ suitability for
working with children or vulnerable adults. We comply fully with the DBS Code of Practice and undertake to
treat all applications to become a volunteer fairly. We undertake not to discriminate unfairly against any
subject of a Disclosure on the basis of conviction or other information revealed.
If you have any unspent criminal convictions please write to the Voluntary Services Manager at St Barnabas
House under separate cover giving details. Having a criminal record will not necessarily bar you from
volunteering with us. This will depend upon the nature of the position and the circumstances and background
of your offences.
St Barnabas Hospices is committed to the fair treatment of its volunteers, potential volunteers regardless of
race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability,
offending background or relationship status.
Agreement and Signature
I agree to be enrolled as a volunteer and to abide by the Volunteer Guidelines and Hospice Policies. I declare
that the information given on this form is true and complete to the best of my knowledge and beliefs.
Name (printed)
Date
Signature
Registered charity number 256789