Version 5 – August 2015

Lay Member to the Stoke on Trent Safeguarding Children Board Application Form

PERSONAL DETAILS

Family name
First name
Middle name
Maiden name
(if applicable)
Title / Mr Mrs Miss Ms Other
(please circle)
Date of birth
Current address
Postcode
Telephone number / Day:
Evening:
Email address
Details of any other previous addresses in the last ten years

EMPLOYMENT HISTORY

Status of employment / Full-time Part-time Not employed
(please circle)
Name of current employer
Address of current employer
Name of previous employers
Address of previous employers
if in further education, please provide details

BACKGROUND AND INVOLVEMENT

You do not need formal qualifications to become a lay member but you do need certain abilities and skills, both to represent your views, and to engage with other members of the Stoke-on-Trent Safeguarding Children Board and other partnership Boards.

PERSONAL ATTRIBUTES

The following questions allow you to outline why you believe yourself to be particularly suited to a role that will provide a unique opportunity to influence the safeguarding of children and young people in the community. Please carefully draw upon your own personal and professional achievements when forming your response.

Why do you want to be a Lay Member?

Please outline the relevant experience that you think equips you to undertake this role and specifically the roles and activities you have undertaken in the last 5 years that indicate your involvement in community and social issues (please use as much space as you require):

Please provide a brief outline of an example where you have made a professional challenge– what was the outcome and how did your challenge make a difference

How do you think you would contribute to the reviewing andmonitoring of the work of the Safeguarding Children Board?

The agencies involved in the work of the Safeguarding Children Board are extremely committed toenabling diversity and promoting equality of opportunity. Whatexperience do you have in respect to this and what does it mean to you?

DBS AND REFERENCES

The role of Lay Member will require a background check (DBS).

Please provide the name and address of two people who can confirm your

engagement with community issues and that in their view you are suitable to act as a LayAdviser:

Reference 1
Name
Address
Telephone Number
Reference 2
Name
Address
Telephone Number

DECLARATION

The information I have provided is true and complete to the best of myknowledge and belief. I confirm that I am eligible to become a Lay Adviser, having given due consideration to the information I have provided in this application form.

If appointed I will be able tocarry out my expected duties and undertake any relevant training.

Signed:

Date:

EQUAL OPPORTUNITY INFORMATION

All Government departments aim to provide fair and equal access to publicappointments. Questions on ethnic origin and disability help us to monitor theeffectiveness of our strategy through information on those applying for andobtaining appointments.

The information given here will not have any bearing on the selection process.

How did you find out about this vacancy?

Ethnic Origin(please tick)

British
Irish
Other white background (please specify)
White and Caribbean
White and African
White and Asian
Other mixed background
(please specify)
Indian
Pakistani
Bangladeshi
Other Asian background
(please specify)
Caribbean
African
Other black background
(please specify)
Chinese
Any other ethnic group
(please specify)

Do you consider yourself to be disabled?

(Please tick)

Hearing impairment
Visual impairment
Speech impairment
Mobility impairment
Reduced Physical capacity
Severe disfigurement
Learning difficulties/disabilities
Mental illness
Physical co-ordination difficulties
Other (please describe)

Please send your application form to:

Carole Preston

Stoke on Trent Safeguarding Children Board Manager

The Civic Centre, Floor 2

Glebe Street

Stoke-on-Trent

Staffs ST41HH

If you have any queries, please contact Carole Preston on: 01782 235863