If You Have Any Difficulty Completing This Form, Please Ask the Home-Start Organiser For

CONFIDENTIAL Home-Start Cotswolds

VOLUNTEER APPLICATION FORM If you have any difficulty completing this form, please ask the Home-Start Co-ordinator for assistance. Title: Full Name:

Any previous name(s): Current address including postcode:

Month and year moved into current address: If you have been at this address less than 5 years please give previous address

Home telephone no.: Nationality:

Mobile telephone Date of birth: no.: Work telephone no.: Place of birth:

Email Address:

Emergency contact name and phone no:

Names of children: Ages of children Ethnic origin (please tick):

 White British  Indian  White Irish  Pakistani  White Other  Bangladeshi  Black Carib  Chinese  Black African  Mixed background  Black Other  Other (please state) ------REFERENCES: Please give the names and addresses of two referees (not a relative) you have known for a minimum of two years. Include at least one professional reference (previous employer wherever possible) or school, college or other professional who may be contacted by Home-Start. Please ask permission prior to submitting referees details and confirm full address. Referee 1 Referee 2 Name: Name:

Address Address

Postcode Postcode E.mail E.mail

Time known Time known and in what and in what capacity: capacity:

Home-Start Cotswolds, c/o Cirencester Baptist Church, Chesterton Lane, Cirencester, Glos. GL7 1YE Charity Number: 1110632. Company Number: 5468592 CONFIDENTIAL Home-Start Cotswolds Please tell us about any paid employment, starting with most recent

Employer and Job title From To Brief description of Reason for leaving duties

Please tell us about any voluntary or unpaid work, starting with most recent

Employer and Job title From To Brief description of Reason for leaving duties

Please tell us about gaps in your employment history, starting with the most recent

From To Reason

Do you speak any additional languages (including sign language) 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 would you use? current clean driving Yes/No licence? Please give information about your own parenting experience: what did/do you find enjoyable and what did/do you find challenging

Home-Start Cotswolds, c/o Cirencester Baptist Church, Chesterton Lane, Cirencester, Glos. GL7 1YE Charity Number: 1110632. Company Number: 5468592 CONFIDENTIAL Home-Start Cotswolds

Have you any skills or personal experiences which may be relevant to your work as a volunteer for Home-Start? (e.g. budgeting, cooking etc)

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

What are your hobbies and leisure interests How did you hear about Home-Start Cotswolds

Is there any other information you would like to add?

As volunteers are in a privileged position visiting families in their own homes and have contact with young 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.

Home-Start Cotswolds, c/o Cirencester Baptist Church, Chesterton Lane, Cirencester, Glos. GL7 1YE Charity Number: 1110632. Company Number: 5468592 CONFIDENTIAL Home-Start Cotswolds Previous convictions do not necessarily preclude you from becoming a volunteer. The age and nature of an offence will be taken into account as part of the assessment of your application. It will be the responsibility of the Management Committee to determine if convictions are relevant to the work of Home-Start Cotswolds.

Full Name:

Have you had any personal contact with Social Services / Social Work Department or NSPCC in connection with children in your care? Have any Yes / No of your children been subject to a child protection, child in need plan or common assessment framework (CAF)? Do you consider yourself to have a disability or health condition and if so Yes / No what adjustments could Home-Start provide to enable you to volunteer? Have you ever been dismissed from any paid or voluntary work? Yes / No Have you ever been arrested or had contact with the police for any type of Yes / No criminal offence? Are there any matters outstanding which may lead to criminal prosecution? Yes / No Do you know of any reason why you would be unsuitable to be a Home- Yes/No Start volunteer? If you have answered yes to any of the above questions please give details below or on a separate sheet in a sealed envelope if preferred.

I will report any changes in my circumstance which may affect my role as a Home-Start volunteer.

I give permission for Home-Start Cotswolds to carry out criminal record checks at enhanced level with the appropriate agency. I understand that my national insurance number, passport and drivers licence may be required for identification purposes.

I give permission for my details to be held on file at the office. I understand that this information remains confidential to Home-Start Cotswolds and will not be passed on to any third party, except for some details such as age, race, sex and disabilities which will be used for monitoring by Home- Start UK for Quality Assurance purposes.

Signed:______Date: ______

Home-Start Cotswolds is committed to safe recruitment practice as an important part of safeguarding and protecting children and vulnerable adults

Home-Start Cotswolds, c/o Cirencester Baptist Church, Chesterton Lane, Cirencester, Glos. GL7 1YE Charity Number: 1110632. Company Number: 5468592