Compassionate Neighbour Application Form

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CONFIDENTIAL

Garden House Hospice Care complies fully with current Data Protection Act 2018 and Freedom of Information legislation. All the information on this form is confidential and will not be shared without your permission. Read our privacy policy here.

Personal Information

First Name:

Last Name:

Street Address:

Town/City:

County:

Postcode:

Email Address:

Ethnicity:

(Not Required)

Mobile No:

No spaces allowed

Home Tel No:

No spaces allowed

Gender:

If Gender is Other, please specify:

Date of Birth:

Click << to change the year and < to change the month.

If you're applying via an organisation, please state which one:

Do you have a disability?:

Please explain disability:

Religion:

Please specify religion:

Emergency Contact Information

Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact - Relationship:

Emergency Contact -Telephone:

No spaces allowed

Reference Information

Please provide the names and addresses of two referees that have known you at least six months or more. These can be teachers, employers or friends, neighbours etc. (including places that you currently volunteer)

1st Reference

Reference First Name:

Reference Last Name:

Reference Email:

Reference Telephone Number:

No spaces allowed

Relationship to you

(e.g. Friend/Manager/ Teacher)

Referee No

2nd Reference

Reference First Name:

Reference Last Name:

Reference Email:

Reference Telephone:

No spaces allowed

Reference Relationship to you:

(e.g. Friend/Manager/Teacher)

Referee No

How did you hear about the Compassionate Neighbour project?

If Other, Please specify

It is extremely useful for us to understand where people hear about our project - please provide details of how you found about Compassionate Neighbours:

Garden House Hospice Care Statement of Confidentiality

I hereby declare that I will hold in strict confidence any information concerning patients, visitors, staff or volunteers and privileged or sensitive information regarding the hospice which may become known to me during the course of my volunteering for Garden House Hospice Care.

I will not divulge such information to any unauthorised person or organisation or discuss such information in any public areas. This will include Social Media and email.

I understand that such confidential or personal information includes a patient’s diagnosis and treatment, particulars relating to his/her admission or condition and any other individual information such as age, address, family details or other circumstances.

I understand that any disclosures of confidential information will result in disciplinary action, which may result in cessation of voluntary duties at the hospice.

Yes

Volunteer Declaration

The information I have given is true and complete. If accepted as a volunteer with Garden House Hospice Care I agree to abide by the policies and guidelines of the organisation. I understand that any false information may result in the withdrawal of any offer of a voluntary role

Yes

Media Consent

I, being eighteen (18) years of age or over, hereby grant permission to Garden House Hospice Care, to interview, photograph, and/or videotape me; and/or to supervise any others who may do the interview, photography, and/or videotaping; and/or to use and/or permit others to use information from the aforementioned interview and/or the aforementioned images in promotional activities including social networking without compensation.

Media Consent

As a Compassionate Neighbour, it is a part of your role to receive emails from the project team to ensure you are kept informed and up to date. These will not exceed one per week. If you would also like to receive emails from the fundraising team about events, campaigns and news relating to fundraising for Garden House Hospice Care, please select below:

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Contact Information