First name*

Surname*

Address line 1*

Address line 2

Town*

Postcode*

Main Telephone No.*

Other Telephone No.

Email Address*

Date of Birth

Country of birth

Gender

Ethnicity

Disability or health condition

Adjustments: If you consider yourself to have a disability or health condition, what adjustments could we provide to enable you to volunteer?

First Language Spoken*

Other Languages Spoken

How did you find out about Home-Start?

Why would you like to volunteer with Home-Start?*

Please use the space below to tell us:1) about your experience of parenting or looking after children under 5. 2) about any skills or personal experiences which may be relevant to volunteering for Home-Start? 3) And any other information you would like to add.

Please tell us about your education, starting with most recent. Please include: 1) Institution2) Subject3) Dates From/To4) Reason for leaving5) A brief description of subject

Please tell us about any voluntary or unpaid work, starting with most recent. Please include: 1) Institution2) Position3) Dates From/To4) Reason for leaving5) A brief description of duties.

Please use the space below to tell us about any paid employment, starting with most recent. Please include:1) Employer2) Job title3) Dates From/To4) Reason for leaving5) A brief description of duties

References: For each referee, please provide:1) full name2) full address3) email address4) phone no. and5) length of time and capacity you have known them for.

1 Have you had any personal contact with Social Services/Social Work Department or NSPCC in connection with children in your care? Have any of your children been subject to a child protection, child in need plan or common assessment framework (CAF)?*

2 Have you ever been dismissed from any paid or voluntary work?*

3 Have you ever been arrested or had contact with the police for any type of criminal offence?*

4 Are there any matters outstanding which may lead to a criminal prosecution?*

5 Is there any reason why you would be unsuitable to be a Home-Start volunteer?*

6 If you answer yes to any question, please give details below:N.B. If you do not declare existing or spent cautions or convictions you may not be selected. However, if you declare any of the above it may still be possible to become a volunteer.

I confirm that I will report any changes in my circumstances which may affect my role (child/ren in care/criminal proceedings brought against me etc) as soon as they occur.*

DeclarationAs you will be completing an Enhanced Disclosure form, details of any criminal convictions or cautions found will be passed on to Home-Start Southwark. Therefore, it is important that you highlight any issue we need to be aware of on your application form. If something is highlighted on your disclosure this will be discussed with you in confidence. Following the meeting a decision will be made whether we can proceed with your application.

• I give permission for Home-Start to carry out a disclosure and barring service check at enhanced level with the appropriate agency. • I understand that my passport, drivers’ licence, birth certificate and/or other personal ID document may be required for identification purposes.• I understand that Home-Start may hold personal information about me in paper records and on their computer, including sensitive information such as age, race, sex and disabilities that they will use for their monitoring purposes. I agree to them holding this information and understand that it may be shared with Home-Start UK for Quality Assurance purposes.• I understand that I may ask to see my records at any time.*