Full Name of the Applicant Date of Birth

APPLICATION TO REGISTER AS A VOLUNTARY ADOPTION AGENCY

PART 1

Name of proposed agency
Address of proposed agency
Post code
Telephone No. / Fax No.
Email address

This application is required to be lodged in person by the proposed responsible individual on behalf of the organisation.

You will be asked to present your application in person bringing your birth certificate, other documents relating to changes of name and a positive proof of identity such as a passport, driving licence etc. This is to enable us to complete identity check procedures required by the Disclosure and Barring Service (DBS) before requesting a disclosure and to evidence other aspects of the registration process. Copies will be retained only for the purpose of registration.

We will also require a passport size photograph of the proposed responsible individual and manager which is a current true likeness; this will be retained as part of your application for the purpose of registration.

Please bring with you the originals of all certificates of qualification upon which your application is based. These will be photocopied and returned to you. You are advised to make an appointment for the purpose of lodging your application and to allow at least an hour for the process.

The form is in 3 parts as follows;

SECTION A Organisation Information

SECTION B Responsible Individual Application

SECTION C Manager Application

Please tick preferred language of written communication:

English Welsh Both

Please ensure that the form is signed, by the necessary persons, in all the relevant places.

SECTION A Organisation information

Name of organisation
The full address of registered or principal office
Post code
Company registration no.
Tel no: / Fax no
Mobile no:
E mail/Website address
Date of establishment of the agency or proposed date of establishment

If the organisation is not a company please provide details of the means by which the organisation was incorporated and the date of incorporation.

If the organisation is a subsidiary of a holding company please provide the name and address of the registered or principal office of the ultimate holding company and of any other subsidiary of that holding company: -

Name of holding company

The full address of registered or principal office
Address of any other subsidiaries of the holding company
Post code
Tel no. / Fax no.
Mobile no.
Email/Website address

If the holding company has had a change of address in the last 5 years please provide details below:

If the organisation is a registered charity, please provide the registered charity number

Please provide details below of the Director, Manager, Company Secretary or other relevant officers of the organisation.

Name of officer of organisation / Position held

Is the agency currently registered for any other purpose: Yes No

If ‘Yes’ please describe: -

the nature of the current registration:

the name address and telephone number of the registration authority

the person dealing with the regulation of your service

Is any other service provided from the premises used for the voluntary adoption agency? / Yes No

If ‘Yes’ please provide details:

Please provide details below of any branch offices of your voluntary adoption agency:

Do you intend setting up any additional branch offices? Yes No

If 'Yes' please provide details including address:

SECTION B Responsible individual within organisation

This section should be completed by the person nominated as “the responsible individual”. He or she must be an individual who is a director, manager, company secretary or other senior officer of the organisation who is responsible for supervising the management of the agency. All personal information relates to the nominated responsible individual

Personal details

Please insert full name of the responsible individual completing this application:
Position held by the responsible individual within the organisation:
Date of birth: / dd/mm/yyyy / Place of birth
Current address of the responsible individual:
Post code:
Tel no: / Fax no:
Mobile no:
E mail address:

If you have changed your name, please provide

· your given names at time of birth and

· ALL former names or aliases you have been known by

Known as / From / To / Reason for change
date of birth

Continue on a separate sheet if necessary

separate sheet attached covering period to

Previous full addresses in the last five years:

From / To
Address
Post code
From / To
Address
Post code
From / To
Address
Post code

Please attach a separate sheet if insufficient space provided for all changes of address within the last five years.

Please tick this box if a separate sheet is attached

Have you ever carried on or managed an

establishment, service or agency*? Yes No

If 'Yes' please provide details in the table below.

Have you ever been refused or had cancelled a registration of an establishment, service or agency registered under the Care Standards Act 2000, Registered Homes Act 1984, The Children and Families (Wales) Measure 2010 or Children Act 1989?

If yes, please provide details in the table below:

(*An establishment means a children’s home, a care home, an independent hospital, an independent clinic, or a residential family centre. An agency means a domiciliary care agency, a nurse’s agency, a fostering agency, an adoption support agency or a voluntary adoption agency. A service includes any day care service for children under 8 years old.)

The name[s] by which the services were known / The nature and dates of the registration decision[s] / Contact details for each registration authority involved / Person dealing with the regulation of that service

Do you have, or have you previously had, a business or financial interest in any other registered service? Please provide details:

Have you ever been disqualified from any of the roles included within the Disqualification from Caring for Children (Wales) Regulations 2004? / Yes No
Have you ever been adjudged bankrupt or had an estate sequestrated? / Yes No
Have you ever made a composition or arrangement with creditors, or been granted a trust deed for creditors? / Yes No

If yes to any of the above, please supply details:

References

Please supply the names and addresses of two individuals from whom we may take up references. You must give the name of your current or most recent employer as one reference. Neither of these referees can be a relative.

Both of these referees must be able to comment on your professional skills and competence relevant to the proposed service. At least one of these referees must have employed you for at least three months. Please supply both address and telephone number.

Name and job title / Address and telephone number / Capacity in which known to the referee.
1.
2.

Qualifications

Please provide details of any qualification (including awarding body and date of award) and professional training relevant to the provision of Voluntary Adoption Agencies.

Qualifications gained / Awarding body / Date of award
(dd/mm/yyyy)

Continue on a separate sheet if necessary, tick if continued

Other relevant information including evidence of fitness and competency as prescribed by regulations 5 & 8 of the Voluntary Adoption Agencies and the Adoption Agencies (Miscellaneous Amendments) Regulations 2003 and the Adoption National Minimum Standards 2003 NMS 14, 15 & 16:

Please outline how you feel you meet these requirements, including any work or training experience you consider to be relevant, whether paid or not.

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Occupational history

Please provide an occupational history covering the period between leaving school and now. Please start with when you left school and provide the year and month of each change of occupation. Include the name and address of any present employer and the names and addresses of any previous employers together with details of the business, which they carried on. If any of your previous duties involved working with children or vulnerable adults, in giving the full reasons why your employment or position ended, please explain how this can be verified.

Where there are any gaps in employment, please give enough detail in your explanation of the circumstances to enable us to make checks if we need to. Continue on separate sheets as necessary Attached are [] extra sheets

Occupation
including job title / From
(mm/yyyy) / To
(mm/yyyy) / Name, address and tel. no. of employer / Reason for leaving and how this can be verified, if applicable. / Indicate if this was working with adults (A) or children(C)
Select(A)(C)
Select(A)(C)
Select(A)(C)
Select(A)(C)
Select(A)(C)
Select(A)(C)

Please use continuation sheets if necessary - tick if enclosed

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Have you ever been subject to any disciplinary action, formal warning, suspension and/or dismissal from a place of employment? Yes No

If ‘Yes’ please provide details:

Are you registered with any organisation that regulates your profession e.g. Care Council for Wales, General Social Care Council, NMC, GMC? If so please give details:

Regulatory body / Registration number / Date due to
be renewed / Revalidation date if applicable / Other information e.g. part / specialist register
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy

Details of membership or registration with other professional or relevant bodies:

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Organisation or professional body / Date: / Type or level of membership/registration
Admitted/ registered / Expiry date
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy

Disclosure and Barring Service

Due to the nature of the role of responsible individual, the post-holder is exempt from s.4(2) of the Rehabilitation of Offenders Act 1974. Rehabilitation of Offenders Act 1975 (Exceptions) Order 1975 (as amended) provides that post-holders are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the 1974 Act.

Are you currently subscribing to the DBS Update Service? Yes No

Declaration

I confirm that on behalf of the Organisation I have read and understood the requirements set out in paragraph 10 Schedule 2 of the Registration of Social Care and Independent Health Care (Wales) Regulations 2002.

The information I have provided in this application form and in any attached documents is, to the best of my knowledge and belief, true and complete. I give my permission for CSSIW to contact relevant persons / organisations to verify the information provided and gather any additional information necessary to progress this application. I understand that the discovery of any deliberate concealment or omission of information could lead to any registration which may be granted as a result of this application being cancelled and may also render me liable to prosecution.

Signed / Date

Proposed responsible individual

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SECTION C Manager application

This section to be completed by the proposed manager of the agency. We will require a passport sized recent photograph, which is a “true likeness”. This will be kept as part of your application and retained on file if registration is granted? Please bring with you originals of your technical and professional qualifications, which will be photocopied and returned to you.

Attach photo here

Personal details

Please insert full name:
Address
Post code
Date of birth / dd/mm/yyyy / Place of birth
Tel no: / Fax no:
Mobile no:
E mail address:

If you have changed your name, please provide

· your given names at time of birth and

· ALL former names or aliases you have been known by

Known as / From / To / Reason for change
date of birth / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy

Previous full addresses in the last five years:

From / To
Address
Post code
From / To
Address
Post code
From / To
Address
Post code

Please attach a separate sheet if insufficient space provided for all changes of address within the last five years.

Please tick this box if a separate sheet is attached

If you have ever owned or managed another registered care establishment or agency, please provide details:

(An establishment means a children’s home, a care home, an independent hospital, an independent clinic, or a residential family centre. An agency means a domiciliary care agency, a nurse’s agency, a fostering agency, an adoption support agency or a voluntary adoption agency. A service includes any day care service for children under 8 years old.)

Owned / Managed
Are you currently registered to provide any other care service from or in connection with the proposed agency premises? / Yes No / Yes No
Do you have any current financial or managerial interest in any other establishment/agency? / Yes No / Yes No
Have you ever carried on or managed an establishment, service or agency? / Yes No / Yes No

Have you ever been refused or had cancelled a registration of an establishment, service or agency registered under the Care Standards Act 2000, Registered Homes Act 1984, Children Act 1989 or The Children and Families (Wales) Measure 2010? Yes No

If yes, please provide details in the table below:

The name[s] by which the services were known / The nature and dates of the registration decision[s] / Contact details for each registration authority involved / Person dealing with the regulation of that service
Have you ever been disqualified from any of the roles included within the Disqualification from Caring for Children (Wales) Regulations 2004? / Yes No

If ‘Yes’ please supply details: