Please note you must be 18 or over to volunteer with us. If you are under 18, please do not apply, as unfortunately we will be unable to accept your application. Which hospital(s) would you like to volunteer at? Please note we are not currently accepting applications for Solihull Hospital. Good Hope Hospital Heartlands Hospital Queen Elizabeth Hospital Birmingham We'd like to know where you heard about our volunteering opportunities, which helps us with our recruitment. Referral source NHS Volunteering website Facebook Twitter (X) Staff referral Volunteer referral Leaflet Event Other (please specify below) Where did you hear about our volunteering opportunities? Personal Details Title Mr Mrs Miss Dr Other Surname First name Preferred name Address line 1 Address line 2 Address line 3 City or town Postcode Email address Main contact telelphone number Alternative contact telephone number Date of birth Gender Male Female Transgender Non-binary Other Emergency contact name Emergency contact relationship Emergency contact telephone number It’s important that you answer the following question in your own words so we can get to know you and your personal motivation for volunteering, so please don’t use AI tools (such as ChatGPT) to assist you in completing this section. If we believe any of your answers are not your own words, then unfortunately we may have to reject your application. Tell us a bit about yourself and why you want to volunteer Inclusion As part of our ongoing commitment to improve our service we would be grateful if you could answer the following questions. Employment status Not currently seeking employment Unemployed but seeking employment In secondary education In higher education Involved in a training scheme Retired Full time employment Part time employment I do not wish to disclose whether or not I am employed Other (please state) If you selected 'other' to the above question, please specify your employment status Nationality Are your day-to-day activities limited because of a health problem or disability which has lasted or expected to last at least 12 months? Yes No Prefer not to say Please select the relevant box or boxes if any of the below apply to you Blind or sight loss Deaf or hearing loss Mobility (e.g. difficulty walking short distances / climbing stairs) Manual dexterity Learning disability where a person learns in a different way (e.g. dyslexia) Mental illness (e.g. schizophrenia / depression) Speech impairment Cognitive disability (e.g. brain injury autism / attention deficit hyperactivity disorder / Asperger’s syndrome) Other impairment (e.g. epilepsy / cardiovascular conditions / asthma / cancer / facial disfigurement / sickle cell anaemia / progressive condition such as motor neurone disease) Prefer not to say Other (please specify) If you selected 'other' to the above question, please specify what applies to you Support worker If you have a support worker please fill in their details. Support worker name Support worker telephone number Support worker address Support worker postcode Ethnicity Choose one section from A to E, then tick the appropriate box to indicate your ethnic group. A: White British / English / Northern Irish / Scottish / Welsh Irish Gypsy / Irish traveller Any other white background (please specify) If you selected 'any other white background' to the above question, please specify your ethnic group B: Mixed or multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other mixed or multiple ethnic background (please specify) If you selected 'any other mixed or multiple ethnic background' to the above question, please specify your ethnic group C: Asian or Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background (please specify) If you selected 'any other Asian background' to the above question, please specify your ethnic group D: Black, African, Caribbean or black British Caribbean African Any other black British African or Caribbean background (please specify) If you selected 'any other black British, African or Caribbean background' to the above question, please specify your ethnic group E: Other ethnic group Arab Any other ethnic group (please specify) If you selected 'any other ethnic group, please specify' to the above question, please specify your ethnic group F: Prefer not to say Prefer not to say Religion What is your religion? No religion Buddhist Christian (including Church of England Catholic Protestant and all other Christian denominations) Hindu Jewish Muslim Sikh Any other religion If you selected 'any other religion' to the above question, please specify your religion Sexuality Which of the following options best describes your sexual orientation? Heterosexual/straight Lesbian Gay Bisexual Other Prefer not to say Rehabilitation of Offenders Act Please give details of any prosecutions pending, bindovers or criminal convictions or cautions you may have had for which you have not yet been rehabilitated. Please also disclose if you have: Any custodial or non custodial conviction Any criminal record held against you, including cautions Any investigations of charges made against you whether as an adult or as a juvenile I am aware that, if appointed to a volunteering role, I have a continued responsibility to inform the Trust immediately if I am charged with any new offence, receive a conviction, caution, warning or reprimand in the United Kingdom or in any other country at any time whilst still a volunteer Do you have any disclosures to make under any of the categories listed above? Yes (please provide details below) No If you answered “yes”, please provide further details below. Any such information will be treated entirely confidentially and will be considered only in relation to applications for positions covered by the Rehabilitation of Offenders Act 1974 (exception order 1975). Failure to disclose such information could result in dismissal. Details of disclosure: Declaration Declaration I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal. How would you like us to contact you? (select all that apply) By email By post By telephone Privacy Privacy statement Submitting this form will send an email to the relevant team. As email communication is not guaranteed to be secure, any personal information is sent at your own risk. We will only use the details of this form to handle your query, including responding to you using the contact details supplied where required. Privacy notice(opens in new tab) Website privacy policy(opens in new tab) To prevent attacks by malicious software, this site is protected by reCAPTCHA, and the Google Privacy Policy and Terms of Service apply. 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