Home-Start Dinefwr

CONFIDENTIAL Volunteer Application Form Home-Start Carmarthenshire 10 High Street 44 Station Road Ammanford Llanelli Carmarthenshire Carmarthenshire SA18 2LY SA15 1AN

Telephone: 01269 593853 / 01554 770808 [email protected]

THIS FORM CAN BE MADE AVAILABLE IN WELSH, IF YOU WOULD PREFER. If you have difficulty completing this form, please ask a member of staff for assistance.

FULL Name including all middle names Address

Postcode If you have been at this address less than two years, please give previous address

Home telephone no.: Work telephone no.:

Email: National Insurance No:

Date of birth: Registered Place of birth:

Next of Kin name and contact number to contact in case of emergency Asian or Asian British Black or Black British White Indian Caribbean British Pakistani African Irish Bangladeshi Scottish Welsh Any other Asian background Any other Black background Any other white background Please specify ______Please specify ______Please specify ______Chinese / other ethnic group Mixed I choose not to respond Chinese Any mixed background Please specify ____ Other CONFIDENTIAL Home-Start Dinefwr

1 of 4 REFERENCES: Please give the name and address of two referees (not a relative) who may be contacted by Home-Start (MUST HAVE KNOWN YOU LEAST TWO YEARS) Please be sure to ask their permission as a delay or refusal may affect you volunteering. Referee 1 Referee 2 Name: Name:

Address: Address:

Email Address Email Address Relationship Relationship

Languages spoken

What is the minimum time you could offer to Home-Start as a volunteer on a regular weekly basis? What type of transport If car - do you have a Yes/No would you use? current clean driving licence and valid insurance? Please give details of any voluntary/paid work you have done, particularly with children and families:

Names of children: Ages of children: Please give information about your parenting experience:

Have you any commitments which could affect your work with Home-Start e.g. part-time work?

What are your hobbies and leisure interests?

2 of 4 Have you any skills or personal / work experiences that you would like to tell us about which may be relevant to your role as a volunteer for Home-Start? Tick all that apply Skills  Personal / Work Experiences  Budgeting / Finance / Benefits Post Natal Depression Cooking Other Mental Health DIY Domestic Abuse Languages Divorce / Separation / Lone parenting Sign Language Bereavement Listening / Counselling Counselling Child Development Disability Committee Work Housing / Homelessness Retailing Substance Misuse Other please specify below Child Care Education Health Social Care Other please specify below

How did you hear of Home-Start?

Why would you like to become a Home-Start volunteer?

Is there any other information you would like to add?

CONFIDENTIAL Home-Start Dinefwr

As volunteers are in a privileged position visiting families in their own homes and have contact with young 3 of 4 children, Home-Start has a responsibility to ensure that no one becomes a volunteer who would misuse this trust. Therefore, it is essential that you complete and sign this form.

Have you had any personal contact with Social Services/Social Work Department relating Yes/No to any children in your care? Have any of your children been subject to a child protection, child in need plan or common assessment framework?

Do you have any medical condition (physical or mental) that could affect your work as a Yes/No volunteer?

Have you ever been dismissed from any paid or voluntary work? Yes/No

Have you ever been arrested or dealt with by the police for any type of criminal offence? Yes/No

Are there any matters outstanding which may lead to a criminal prosecution? Yes/No

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

If you do not declare existing or spent cautions or convictions, this may affect your recruitment as a volunteer. However, if you declare any of the above it may still be possible to become a volunteer.

I give permission for Home-Start to carry out criminal record checks at enhanced level with the Criminal Records Bureau. I understand that my National Insurance number may be required for identification purposes. I know of no reason why I would be unsuitable to be a Home-Start volunteer and will report any changes in my circumstances which may affect my role. I understand that Home-Start may hold personal information about me in 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 and funding bodies for Quality Assurance and statistical purposes.

I understand that I may ask to see my records at any time. My file is kept under the Data Protection Act and I must give suitable notice of my intention to view my file. Any information kept is confidential and will only be shared on my consent. However, any information will be shared with the relevant authorities if staff feel the safety / welfare of my child/ren or children connected with me are at risk.

Print Name…………………………………….Signed: ………………………………… Date: ………………………..

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