VOLUNTEER APPLICATION FORM HOSPICE MID CANTERBURY – VOLUNTEER APPLICATION FORM–None–AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos IslandColombiaComorosCongoCook IslandsCosta RicaCote DIvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHawaiiHondurasHong KongHungaryIcelandIndonesiaIndiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalaysiaMalawiMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlands (Holland, Europe)NevisNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarRepublic of MontenegroRepublic of SerbiaReunionRomaniaRussiaRwandaSt BarthelemySt EustatiusSt HelenaSt Kitts-NevisSt LuciaSt MaartenSt Pierre & MiquelonSt Vincent & GrenadinesSaipanSamoaSamoa AmericanSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUnited KingdomUkraineUnited Arab EmiratesUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wake IslandWallis & Futuna IsYemenZaireZambiaZimbabwe–Ethnic Origin–1 – European11 – New Zealand European128 – Australian2 – Māori3 – Pacific Peoples4 – Asian42 – Chinese43 – Indian5 – Middle Eastern/Latin American/African53 – African6 – Other Ethnicity99 – Not Stated –None–YesNo Please bring your driving licence at the time of interview.Please bring Second ID as well along with your driving licence at the time of interview.–None–YesNo Activities you would be willing to undertake as a volunteerClient Contact Services AssessorBiography ServiceClient TransportShoppingCompanionship / SittingPet MindingExercise ClassOvernightReceptionActivitiesPhotographyOutingNon-Client Contact ShopBakingFundraisingOther SupportCleaningGardeningAdmin Reference Detail Do you have any criminal convictions or any major charges currently pending against you? (Please note that we require consent for police vetting from all applicants. You will be asked to complete this at your interview with the manager of volunteer services.):–None–YesNoIf you answered yes, what was the offence and when did it occur: Criminal Conviction DetailsIf placed in a volunteer position I agree to Follow Hospice Protocols:–None–YesNoSTATEMENT OF CONFIDENTIALITY Clients and families involved with Hospice Mid Canterbury are accorded confidentiality. As a volunteer with this organisation, I agree to respect and maintain this trust. I AGREE to my name and phone number being used within the Hospice. The personal information contained in this form will be held by and remain confidential to the management team of Hospice Mid Canterbury. Under the Privacy Act 1993, I have the right to request access to, and correction of, any of my personal information held by the Hospice. Agreed on Statement of Confidentiality:–None–YesNo DECLARATION I DECLARE THAT all information provided by me in support of my application is correct. I acknowledge that if I have provided incorrect or misleading information or omitted information of significance, or if I fail to notify Hospice Mid Canterbury of changes in the information provided, I may no longer be accepted as a volunteer. Declaration of Correct Information:–None–YesNo
