Wufoo

Volunteer Nurse application form

This form is to be completed by all those applying to be a nurse with Camp Quality UK. --Please email chris@campquality.org.uk if you have any questions about this form.--

Please note you must be a current, fully registered, nurse and have lived in the UK for the last three years to be a nurse on a Camp Quality UK holiday.

Your details (1 of 6)

Introduce yourself!
Your name * Title First Last Suffix
Address line 1 *

ie 123 Acacia avenue or flat 4
Address line 2

ie Middlesthorpe, or University Halls
Postcode *

You know this bit!
City (postal town) *

ie London or Leicester
Contact number 1 *

What's the best number to get you on?
Contact number 2

If the first number doesn't work, becuase you've changed your number, lost your phone or moved house. It's useful to have an alternative number to contact you on.
Email *

Whichever one is least likely to change
Date of birth * DD / MM / YYYY
ie 5 October 1980 is 05/10/1980
RCN or Unison number
NMC number

Note: you must have full, current, NMC registration
Which part of the register are you on (RNA or RNC)?
RNA (adult) RNC (child)
Your current or most recent job (2 of 6)

What are you doing currently? Please note we may contact your current employer for a reference.
Job title (inc band number) *

ie Nurse specialist in paediatrics or staff nurse
Place of work *

ie Ward 16 at St James', Leeds
Work address 1 *

ie Birmingham Children's Hospital
Work address 2 *

ie Acacia Avenue
City (postal town) *

ie London
Postcode *

You know this bit
Name of manager (referee) * Title First Last Suffix
We may contact your current workplace for a reference
Contact number for manager *

Please tell them we may be calling
Email address for manager

Please tell them we may be emailing them too. An NHS account is preferred.
Your training and experience (3 of 6)

A bit about what you've done
A brief history of your work experience

Your past job titles - not too much detail
Any specific training you have received and any experience you have with children

Are there any specific qualifications that you have received that you'd like to tell us about? Particularly oncology, acute medicine or paediatrics. Your experience with children may be from home, work or elsewhere. Include past experience at Camp Quality or other organisations.
Experience with the following
Hickmann/central lines PEG feeds and pumps Chemotherapy medication First aid

Which of these are you comfortable with? If we or you feel that you need training on any of these before camp we may be able to arrange it for you.
A little more about you (4 of 6)

Some of the finer details
What is your adult shirt size

You may be given a Camp Quality t-shirt, so we need to know what size to order for you.
Do you have any special dietary requirements or medical conditions?

Just so we know... we need to make sure you're taken care of too!
Why do you want to be nurse on a Camp Quality UK holiday and what do you think you'll bring, other than your medical abilities?

In psyche-babble: "What's your motivation?"
Which holiday(s) would you like to volunteer on?
Dukes Barn 22-25th May 2009 (7-11yrs) York Dungeons 24th October 2009 (12+yrs) Overstrand 6th-8th November 2009 (14-16yrs)
References (5 of 6)

Details of a referee who we may contact. They must be someone outside of your family who you have known for more than 2 years. We may also contact your current employer (see section 2, above) for a reference.
Name of referee * Title First Last Suffix
Please tell them we may be contacting them
Address line 1 for referee *
Address line 2 for referee
City (postal town) for referee *
Postcode for referee *
Contact number for referee *

The number we're most likely to be able to contact your referee on
Email address for referee *

Preferrably a work email address or professional one (ie doctors.org.uk)
Your relationship to referee *

Remember, they must be someone outside of your family who you've known for 2 or more years
Declaration (6 of 6)

Don't worry, we're nearly there. Please read the declaration below very carefully. The Guidelines for Companions and Staff can be found here: www.campquality.org.uk/how-you-can-help/non-medical-volunteers
I certify that all the information given by me in this application is true and correct to the best of my knowledge. I agree that, should my application become successful, I will hold myself bound by the rules and policies of Camp Quality UK and in particular by the Guidelines for Companions and Staff which I have read and understood. I am not currently under investigation for any offence. I give Camp Quality UK permission to contact my referees and obtain information about me. We may use your contact details to process your application and let you know about any news at Camp Quality UK. We will not pass your details onto a third party, unless stated otherwise. *
I agree to and accept these terms and conditions

Please take a moment to read this carefully and read the Guidelines for Companions and Staff first.
Do Not Fill This Out

Wufoo

Volunteer Nurse application form

Your details (1 of 6)

Your current or most recent job (2 of 6)

Your training and experience (3 of 6)

A little more about you (4 of 6)

References (5 of 6)

Declaration (6 of 6)