SAH Volunteer Application Form - St Ann's Hospice

DisabilityThe Disability Discrimination Act defines disability as ‘a physical or mental impairment which has asubstantial long-term adverse effect on a person’s ability to carry out normal day-to-day activities’.Do you consider yourself to be disabled in line with theabove definition?If yes, please state the nature of your disability YES NOEqual OpportunitiesSt Ann's Hospice has an Equal Opportunities policy, the aim of which is to ensure that no applicant or volunteerreceives less favourable treatment or is disadvantaged by requirements which cannot be shown to be justified. Inorder to ensure that this policy remains effective, you are requested to answer the following questions (but it isnot a legal requirement). This form will be treated in the strictest confidence and is designed formonitoring purposes only.Gender: MALE / FEMALEMarital Status: SINGLE / MARRIED / CIVIL PARTNERSHIP / LIVING WITH PARTNER / OTHERIf other please specify:ETHNIC ORIGIN (please tick) : White British White Irish Any other white background Mixed – White & Black Caribbean Mixed – White & Black African Mixed – White & Asian Any other mixed background Chinese Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi Any other Asian background Black or Black British - Caribbean Black or Black British – African Any other Black background Any other background (please state)………………… Do not wish to give detailsPrior to the commencement of any voluntary role, you will be asked to attend an informal interview and yourreferences will be requested. A Criminal Records Bureau Disclosure will be undertaken for all posts based withinthe hospice (this includes Heald Green, Little Hulton and The Neil Cliffe Centre). Although convictions will notnecessarily be a bar to you obtaining a voluntary position with us, these checks enable us to make saferrecruitment decisions for the benefit of our patients.Have you ever been convicted, cautioned, reprimanded or given a warning for a YES*criminal offence? NO*If Yes, please give details on a separate sheet and enclose in a sealed envelope marked For the attention ofPersonnel Director, and return with your completed application form.DeclarationI understand that I am not applying for a paid position. I declare that to the best of my knowledge theinformation I have given on this form and accompanying documents is true and current. I understand thata false statement may result in termination of a voluntary appointment made from this application.Signature:Date:St Ann’s Hospice is a registered charity, number 258085.