Wufoo

Volunteer Doctor application form

This form is to be completed by all those applying to be a doctor with Camp Quality UK. The intent of this form is two-fold:
1. To help Camp Quality UK provide a safe and secure environment for those children and young people who participate in it’s programmes and activities.
2. To assist Camp Quality UK in matching the applicant’s abilities to the needs of particular holidays.
--Please email chris@campquality.org.uk if you have any questions about this form.--

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

Your details (1 of 5)

Introduce yourself!
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?
Email *

Whichever one is least likely to change
Date of birth * DD / MM / YYYY
ie 5 October 1980 is 05/10/1980
Sex *
Male Female
Place of work

ie Paediatrics at St James', Leeds
Job title (inc career level)

ie Specialist registrar in haematology or junior partner at GP practice
GMC number

Note: you must have full GMC registration
Medical defence union (or equivalent) number
Your training and experience (2 of 5)

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

Are there any specific qualifications that you have received that you'd like to tell us about?
Your experience with children and young people

Either at home, work or elsewhere. Include past experience at Camp Quality or other similar 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.
Upload your CV - optional

If you'd like to, you may upload your CV, to enable us to get a fuller picture about you and your career. But we won't hold it against you if you don't!
A little more about you (3 of 5)

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 a doctor on a Camp Quality UK holiday and what do you think you'll bring to the holiday, other than your clinical 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 Overstrand 6th-8th November 2009 (14-16yrs)
References (4 of 5)

Details of referees who we may contact. These must be people you have known for more than 2 years and who aren't members of your family
Name of referee 1 Title First Last Suffix
Address line 1 for referee 1 *
Address line 2 for referee 1
City (postal town) for referee 1 *
Postcode for referee 1 *
Contact number for referee 1 *

The number we're most likely to be able to contact your referee on
Email address for referee 1 *

Preferrably a work email address or professional one (ie doctors.org.uk)
Your relationship to referee 1 *

Remember, they must be someone outside of your family who you've known for 2 or more years
Name of referee 2 Title First Last Suffix
Address line 1 for referee 2 *
Address line 2 for referee 2
City (postal town) for referee 2 *
Postcode for referee 2 *
Contact number for referee 2 *

The number we're most likely to be able to contact your referee on
Email address for referee 2 *

Preferrably a work email address or professional one (ie doctors.org.uk)
Your relationship to referee 2 *

Remember, they must be someone outside of your family who you've known for 2 or more years
Declaration (5 of 5)

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. I hereby waive any right to inspect references so given. 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 Doctor application form

Your details (1 of 5)

Your training and experience (2 of 5)

A little more about you (3 of 5)

References (4 of 5)

Declaration (5 of 5)