This year we have a number of governance positions. All applicants will be screened using this form and the criteria specified on the role descriptions. We begin with the selection of co-opted trustees, followed by a ballot for theelected trustee vacancy and then theappointment of sub-committee members. Therefore we would ask you to indicate which of the following you would like to be considered for (as an example, you may apply for a co-opted position on Council, but if unsuccessful and you are willing to be put forward for the election or a position on a sub-committee, please also tick the relevant boxes):

Co-opted trustee position - BME
Co-opted trustee position - Wales
Elected member of the trustee board
Co-opted member of External Relations sub-committee
Co-opted member of Networks and Communities sub-committee

APPLICANT’S DETAILS

Title: / First Name: / Surname:
Are you a member of Mind / Mind membership No: (if known)
Yes/No (delete as applicable)
Home address:
Post Code:
Telephone No’s: (please include full STD code)
Home Tel:
Mobile Tel:
Work Tel:
Email:

Please tick your preferred contact number

(A) INTEREST AND EXPERIENCE

Please provide a personal statement explaining your interest and experience in mental health and Mind and why you are interested in being part of Mind’s governance using no more than 500 words.

For elected positions this will be used as your electoral statement in the event of a ballot

(B) PERSONAL COMPETENCIES

Please tell us how you meet the personal competencies giving examples from your paid or voluntary work, life experiences or training to show us that you have the necessary skills and experience to meet these criteria.

Competency / How met
Understanding and commitment to Mind’s Vision, Mission and Values
Knowledge and/or interest in mental health issues
Ability to work effective in a group and take part in discussions
Ability to manage difficult and/or challenging situations
Ability to challenge constructively and ask questions appropriately
Ability to analyse information
Willingness to abide by the expectations of Council of Management members

(C) SKILLS AUDIT

To be effective the Council of Management and sub-committees need a range of skills, personal experience and diversity and we conduct skills audits and maintain a skills register to identify possible gaps and guide the board when appointing new trustees to ensure that the governance committees are appropriately balanced.

Please indicate the skills, experience and knowledge you would bring to Mind using the definitions below to indicate your level of expertise:

i.Level Ais a level of skill/knowledge characterised by having qualifications and professional experience sufficient to be able to take a leadership role in this area with a board of trustees of a national charity. You will probably have experience of the area at a senior level, and/or a postgraduate qualification. For example, a chartered accountant, with experience and track record in responsibility for charity finance management or governance, would be expected to tick Level A in the finance category. Someone with a current or previous senior management position and qualifications would be expected to tick Level A for general management.

ii.Level B is a level of expertise where a person has experience and/or qualifications, and been responsible for (in a paid or voluntary capacity) the skills area, but who would not be considered at the level of expert. This could include holding a role with designated responsibility for contributing to equalities and diversity targets, for the diversity category, or budgetary responsibility, for the finance category.

iii.Level C is a level of skill where a person has lay knowledge, and is familiar enough with the area to contribute to Council discussion, form an opinion, vote if required, understand the implications of, and take responsibility for, Council decisions.

Skills/knowledge/experience / and level
(A,B or C) / How do you have these skills, knowledge and experience and how would you contribute them to the Council of Management
Essential(trustee role only)
Strategic planning
General management skills
Finance
Governance
Desirable(for board as a whole/specific to sub-committees)
User-engagement
Mental health policy/issues
Diversity
Service provision
Fundraising/income generation
Communications
Federal structures
Local Mind associations
Media work
Training
Grant making
Policy influencing/implementation
Campaigning
Retail
Legal
Human resources
IT
NHS/LA/Voluntary sector
Performance-management
Organisation development
Quality systems
Publications
Marketing

Are there any areas of work you have a particular interest in and/or would like to become involved in?

(D) DIVERSITY MONITORING

The information provided is used to audit the diversity of our governance and identify support needs. Any information provided will be treated confidentially and will only be made more widely available with the explicit consent of the individual.

What is your gender? (please tick/specify)
Male
Female
Transgender
/ What is your date of birth?
To be eligible you must be 18 by the date of appointment

Ethnic origin:

White / Black
British / Caribbean
Irish / African
Any other White background / Any other Black background
Asian or British Asian / Mixed
Indian / White & Black Caribbean
Pakistani / White & Black African
Bangladeshi / White & Asian
Any other Asian background / Any other mixed background
Chinese or other Chinese / Gypsy or Traveller
Chinese
Any other Chinese background / Other ethnic origin
Please specify:
Do you live in England or Wales?
England
Wales
/ Do you consider yourself to be disabled?
Yes
No

How would you describe your sexuality?

Bisexual / Heterosexual / Prefer not to say
Gay / Lesbian
Would you describe yourself as someone who is or has experienced a mental health problem?
Yes
No
/ If, Yes, when was your last experience?
Less than 1 year ago
1-2 years
2-5 years
5-10 years
10 years +
How have you managed your mental health?See below for definitions
Self care
Social support
Primary care
Secondary care
/ Have you ever been section under mental health legislation?
Yes
No
Have you experience as an unpaid carer of someone who is or has experienced a mental health problem?
Yes
No
/ Are you able to draw on any of the following experiences and knowledge of mental health? (please tick all that apply)
Mental health advocate
Mental Health professional, i.e. nurse, psychiatrist, social work, counsellor
Paid of voluntary work
Mental Health policy work at a national level
None of the above
Are you actively involved in a local Mind association?
Yes
No
/ If Yes, in what capacity?
A staff member
A volunteer
A trustee
A user of Mind services

Are you willing to share this information internally within the organisation?

Yes
No
Not all aspects / Please specify:

Do you require any reasonable adjustments to the screening process?(For example physical access, communication support, personal support)

If you were successful, would you require any reasonable adjustments to help you carry out your role?

Definitions:

Self care:

/

Personal coping strategies

Social support:

/

e.g. Friends, Family, Carers, drop in centres, voluntary/community group services

Primary Care:

/

e.g. GP, services from a local surgery or community/voluntary based health services

Secondary care:

/

e.g. mental health outreach team, psychiatric referral, community mental health team, community psychiatric nurse, voluntary hospital stay, sectioned hospital stay

REFERENCES:

Please give the name, address and position of two referees. References will only be taken up for successful candidates. References from friends and relatives are not acceptable.

Name:
Position held:
Organisation:
Address:
Telephone No:
Email Address:
Name:
Position held:
Organisation:
Address:
Telephone No:
Email Address:

DECLARATION:

I have read and understood the role description, Code of Conduct and details on the eligibility to be a trustee and I confirm that the information I have given is true and correct. I confirm that if elected or appointed, I will fulfil the obligations laid down to the best of my ability.

I have completed and enclose the:

  • Declaration of Eligibility 

Please note that in accordance with Mind’s Memorandum and Articles of Association, to serve as a trustee you must be a fully paid up individual member of Mind

Signed:
Date:

Please return completed forms to:

Chief Executive’s Office, Mind, 15-19 Broadway, Stratford, London, E15 4QF

DECLARATION OF ELIGIBILITY TO BECOME A TRUSTEE

I declare that I am not disqualified from acting as a charity trustee and that:

  • I am over age 18 at the date of appointment.
  • I am capable of managing and administering my own affairs;
  • I am not disqualified under the Independent Safeguarding Authority (ISA) Adults’ Barred List (formerly the Protection of Vulnerable Adults List)
  • I am not an undischarged bankrupt.
  • I have not previously been removed from trusteeship of a charity by a Court or the Charity Commission.
  • I am not under a disqualification order under the Company Directors' Disqualification Act 1986, or to an Order made under section 429(b) of the Insolvency Act 1986
  • I have not been convicted of an offence involving deception or dishonesty
  • I have not been convicted of a sexual offence(s)
  • I do not have any financial interests in conflict with those of Mind (either in person or through family or business connections) except those which I have formally notified in the conflict of interest declaration.
  • I will abide by the Code of Conduct.
  • I give my consent for the charity to carry out relevant checks on me including, if necessary, identity checks, Criminal Records Bureau (CRB) checks and checks against the Charity Commission’s list of removed or disqualified trustees.
  • I give my consent for Mind to hold my personal details within a manual or electronic filing system in relation to the Data Protection Act 1998.
  • I understand that to knowingly make a false statement is a criminal offence under section 11 of the Charities Act 1993 and a false declaration could result in my removal as a trustee.
  • I have read and understand the role and responsibilities of a trustee and undertake to fulfil my responsibilities and duties as a trustee of Mind in good faith and in accordance with the law and within Mind’s objectives and Mission.

Name: (please print)
Signed:
Date: