Online Application Form

Please complete the form in full and then click submit.

Name: *
Address: *
E-mail: *
Home Phone:
Mobile Phone:
Date of Birth: *
How did you hear about Hospital Radio Stafford?
Why do you wish to join Hospital Radio Stafford?
Have you done any voluntary work before? (not essential but any experience you can bring to us is useful)
I could be available on any of the following times: (whilst we need a regular commitment, this does not commit you in any way - It is a helpful indication for us)
I would be able to visit patients in
Please supply the name and contact details for a referee who is not a family member?
Reference Address:
Reference E-mail: (if possible)
Reference Phone: (if possible)
CONFIDENTIAL - Please note that a DBS (Disclosure and Barring Service) check will be required to be completed by the University Hospitals of North Midlands NHS Trust Human Resources Department.
Declaration by all Staff and Volunteers - Have you ever been convicted of a criminal office or been the subject of a caution or of a Bound Over Order ?
If yes please state below the nature and the date(s) of the offence
Are you happy for your details to be securely stored by Hospital Radio Stafford electronically and not passed to any other body?
If under the age of 18 this application must be approved by a parent or guardian. Provide Name and Contact number for this can be checked.
Parent Phone:
Please enter YOUR name as a signature:
Recaptcha Word Verification: