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    Your Details

    Your Title (required)

    Forename(s) (required)

    Surname (required)

    Former Name (required)

    Telephone Number (Day) (required)

    Telephone Number (Evening) (required)

    Telephone Number (Mobile) (required)

    Your Email (required)

    Your Postal Address (required)

    Your Areas of Interest

    Day Centre AssistantComplementary TherapyCharity ShopVan DriverVan AssistantDay Centre DrivingReceptionist/ AdministrationBefriendingFundraising Campaigns and EventsOther

    If there is a specific volunteering role in which you are interested, please give details here:

    Relevant Experience

    Please summarise any experience (either paid work, voluntary work or other experience), Skills or qualifications which you consider to be relevant to the volunteering opportunity in which you are interested.

    Experience, learning and skills

    Information to support your application


    When are you available?
    Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMSunday PM


    How would you travel to the place of volunteering?

    Driving License

    If you wish to volunteer as a driver, please complete this section:

    (NB we will need to see your driving licence, insurance policy and MOT Certificate, if applicable)

    Do you have a valid UK driving licence?

    License Expiry Date

    Who is your vehicle insured with?

    Insurance valid until

    Car Registration

    Details of endorsements


    Do you consider yourself to have a disability or support needs that are relevant to your application?

    If yes, is there anything that we need to know about your disability or support needs in order to ensure you have equal opportunity?

    Emergency Contact Details

    Please supply the name and contact details of at least one person we may telephone in the case of illness or emergency.

    Contact 1



    Contact 2



    Cautions, Rehabilitation and Criminal Records

    Please give details of any criminal convictions. If none, please state.

    Rehabilitation of Offenders Act 1974, (Exemptions) Order 1975

    For certain volunteering roles which involve contact with vulnerable people, including children or patients of Hospice of the Valleys, you are not entitled to withhold information about convictions which are for other purposes 'spent' under the provisions of the Act. Successful applicants will be required to complete a Disclosure Application at Enhanced level for submission to the Criminal Records Bureau. Hospice of the Valleys complies fully with the DBS Code of Practice and the Data Protection Act 1998 regarding disclosure information. Any information given will be treated as completely confidential and will only be considered in terms of its relevance to an application for positions to which the order applies. A criminal record will not necessarily be a bar to obtaining a position. If you have any concerns or queries on this matter, please seek advice from the Volunteer Co-ordinator.


    We ask you to provide details of two references who are not directly related to you, who are independent of Hospice of the Valleys and who have known you for at least two years.

    Business Reference (e.g employer, doctor, teacher, solicitor)





    Email Address

    Your relationship to referee

    Years Known

    Personal Reference (Note: We do not accept references from family members)





    Email Address

    Your relationship to referee

    Years Known

    Background Information

    Have you had a recent bereavement of a close family member or friend?

    We advise a person who has had such a bereavement not to volunteer at Hospice of the Valleys until at least one year has elapsed. If, however, you feel able to volunteer and would like to discuss the possibility of doing so, please contact the Volunteer Co-ordinator, who will be happy to discuss this with you.

    How did you find out about volunteering with Hospice of the Valleys?


    The information I have given in this application is true and complete

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