Ward Visitors

TITLE/FIRST NAME:
SURNAME:
HOME ADDRESS:
POST CODE:
TELEPHONE (HOME):
TELEPHONE (WORK):
TELEPHONE (MOBILE):
E-MAIL ADDRESS:
DATE OF BIRTH: (Please note: We can only accept members over the age of 18 - this is a requirement of the hospital))	DAY: MONTH: YEAR:
OCCUPATION:
OTHER INTERESTS:
Please tell us why you want to join Hospital Radio Basingstoke and what you feel your membership would contribute to the station:
Have you any past experience within the radio industry (including student radio and other hospital radio stations?)
If you have answered "Yes", please give details:
Have you ever been involved with or associated with a pirate radio station?
If you have answered "Yes", please give details:
Have you ever been involved in a charity organisation?
If you answered "yes", please give us details.
Please give some idea of when you might be available to visit the wards
Please supply the names and addresses (including post code) of two people who have agreed to act as referees, one of which should be a current or previous employer (or department head at college). Neither should be an existing member of HRB. NOTE: We cannot take your application any further without the full names and contact details (postal address) of two referees. Both referees will be contacted during your provisional membership period.
NAME: ADDRESS: POST CODE:
Relationship to you:
NAME: ADDRESS: POST CODE:
Relationship to you:
*Membership is renewed annually on January 1st and will cost £10 per year for ward visitors.* During the time of your provisional membership, we will follow up all references and all new members will be expected to complete and return a police check form. Until the police check form has been processed, you will not be allowed onto the wards unsupervised and you cannot become a full member of the station. You will be expected to complete a police check form within 1 month of starting your membership - this involves providing 2 forms of identification. By submitting this form, you agree to complete the CRB form within one month of starting your membership. *You will also be asked to complete a form to apply for a parking permit in order to park at North Hants Hospital.* During your first month, we will ask you to spend at least one evening at the studio with the presenters for that evening to listen to the station and see how it all sounds/works. I authorise Hospital Radio Basingstoke to approach the above named referees for a personal reference on my behalf. By submitting the above, I declare that the information supplied is correct to the best of my knowledge and I agree that I will complete a police check form before I can be accepted as a full member of the station. By entering my name below, I am certifying that I have completed the form myself I have checked all of the information above. NAME: DATE:
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