Compass Carers’ Service

Steering Group member application form

Compass Disability Services have been commissioned to deliver a service that will help carers build capacity in their caring role and also seek, with them, ways to improve their own health and well-being. The user – led Steering Group will guide the implementation, delivery and development of this service.

Office Use Only. Code

Section 1

Name:

Address:

Post Code:

Telephone Number:

Mobile Number:

Email Address:

Are you a disabled person? Y / N

Do you have any needs we should meet in order to offer you a fair interview? (E.g. wheelchair access, BSL interpretation, etc?). If so, please detail below:

Signed:

Date:


Section 2

·  I understand and can demonstrate an understanding of a commitment to carers’ needs and equality of opportunity for all people within the community.

·  I am prepared to work constructively in consultation with others to develop plans and policy.

·  I am willing to speak, act and make decisions on behalf of a large and diverse range of people.

·  I am able to understand budgetary issues sufficiently to review the monthly financial analysis produced by the Service Project Manager

·  I have not been convicted of an offence involving deception ordishonesty (unless the conviction is spent).

·  I undertake to fulfill my responsibilities and duties as a member of the ‘Compass Carers’ Service’ Steering Group in good faith and in accordance with within Compass Disability Services’ objectives / mission.

·  I do not have any financial interests in conflict with those of the Compass Disability Services’ (either in person or through family or business connections) except those which I have formally notified in a conflict of interest statement.

Signed: ______

______(Name in Capitals)

Date: ______

.
Section 2 Cont.

Please note that this post is subject to a Criminal Records Bureau (CRB) Enhanced Disclosure. We encourage all applicants called for interview to provide details of any criminal record at an early stage in the application process. If relevant, we request that this information is sent under separate, confidential cover, to the Chief Executive Officer of Compass Disability Services, at the address below. We guarantee that this information will only be seen by those who need to see it as part of the recruitment process. Having a criminal record will not necessarily bar you from volunteering with us. This will depend on the nature of the position and the circumstances and background of your offences. Compass Disability Services adheres to the CRB Code of Practice, a copy of which is available on request.

Office Use Only. Code

Section 3.

1.  Please give a description of your experience of a being a Carer.

2.  Please provide details of the skills you have, as described in the Roles and Responsibilities document relevant to this application.

3.  What motivated you to apply to become a member of the Compass Carers’ steering group?

4.  Which aspect of Compass Carers, if any, do you have a particular interest in?

5.  How much time (approximately) would you be willing to commit to the Steering Group?

6.  Do you currently serve on the board of any other charity/committee?

Yes No

If “Yes” please detail what board you sit on and in what capacity.

7.  We are seeking representatives from each of the nine GP Federation areas, as detailed on Appendix 1 attached. Please tick the location in which you live.

West Somerset Sedgemoor North East Mendip

Bridgwater Bay West Mendip Chard, Crewkerne,

Ilminster

Taunton and Area Central Mendip South Somerset

Other, please explain

Please return your completed application to:

Jane Allin, Volunteer Coordinator, Compass Disability Services, Unit 11-12 Belvedere Trading Estate, Taunton, TA1 1BH or email

Appendix 1

The nine GP Federation Areas

/ West Somerset / / Sedgemoor North / / East Mendip
/ Bridgwater Bay Health / / West Mendip / / Chard, Crewkerne, Ilminster
/ Taunton and Area / / Central Mendip / / South Somerset Healthcare
Date updated: 21/08/2013 / By whom: Jane / Version number: 3
Location: Z:\Compass Files\Staffing and Recruitment\Job Descriptions\Volunteer Job Descriptions\Steering Group Application form.doc