First name*

Surname*

Address*

Town*

Postcode*

Main Telephone No.*

Email Address*

Emergency contact number and phone*

Date of Birth*

Gender

Ethnicity

Other Ethnic Background

Main Disability

Other Disability, Physical or Mental Health Condition

Employment Status - FT/PT

Employment Status - Unemployed

Employment Status - Retired

Employment Status - Student

Employment Status - Carer/Homemaker

Primary Language Spoken*

Other Languages Spoken

For each of your two referees, please provide:
1) full name,
2) full address,3) email address,
4) phone no. and
5) length of time and capacity you have known them for.

Please us the space below to tell us about any paid employment, or volunteering experience you have starting with most recent.
Please include:
1) Employer
2) Job title
3) dates From/To
4) Reason for leaving and
5) a brief description of duties.*

Please use the space below to tell us about your experience of parenting or looking after children under 5. If you have children, please give their dates of birth.*

Please use the space below to tell us about any personal or professional skills which may be relevant to your volunteer at Home-Start. For example:
- Budgeting, finance, benefits
- Cooking, DIY
- Committee work
- Counselling or experience with post-natal depression, mental health, domestic violence, divorce, bereavement, advocacy, housing, childcare, etc.*

How did you find out about Home-Start*

Why you wish to volunteer with Home-Start? This could be:
a) to gain new skills/experiences for employment
b) to access opportunities for training and development
c) to give something back to communities
d) to build confidence
or any other reason.*

Name of College and course:

Please provide the details of your placement coordinator, tutor or supervisor whom we could contact for an additional reference. Please provide their Name, Organisation (if applicable), Address, Postcode, Email and Telephone

Please confirm if you are in receipt of your own personal therapy

Please confirm if you have student insurance: (Note: you will be asked to bring proof of insurance if invited to interview)

Supporting Statement
Please use this space to tell us why you feel you would be suitable for this role. Please consider the advertisement and tell us about your knowledge, experience and interests relevant to the skills required.

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)?*

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

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

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

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

If you answer yes to any question, please give details below:

We conduct an enhanced Disclosure and Barring Service check for all volunteers. You must declare existing or spent cautions or convictions. If you do not declare any 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. For more details, contact the Scheme Manager.

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.*

Declaration
As you will be completing an Enhanced Disclosure form, details of any criminal convictions or cautions found will be passed on to Home-Start. 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 National Insurance number, passport and/or drivers’ licence 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.
If you have any concerns please discuss this further with Thienhuong Nguyen, Scheme Manager *