1. Your personal and contact details

Title (e.g. Mrs., Mr., Ms. Etc.) / Gender: / Male ☐ / Female: ☐
Last Name: / First Name(s):
Date of Birth (DD/MM/YYYY) / Telephone Numbers: / Daytime: / Mobile:
Home Address: / Correspondence Address (if different from home address)
Postcode: / Postcode:
County: / County:
Email: / Email:

Independent Stalking Advocacy Caseworker Accredited Training Application Form

Please note that this form will be photocopied. Please type or write clearly in block capitals in black ink and tick boxes as appropriate

  1. Nationality

Country of birth:
Nationality:
  1. Criminal Convictions

Do you have any criminal convictions?
  1. Work Experience
Your application will be considered on the basis of your work and other relevant experience. You should therefore give full and
accurate details of all your relevant previous work experience in this section
Name of Current Employer: / Line Manager name:
Employers Address: / Line manager contact number:
Postcode: / Line Manager email:
County: / Correspondence Address:
Email:
Previous employment
Name and Address of Organisation: / Job Title and Brief Summary of Role / Dates of Employment
  1. Financial Information

How will the course fee be paid?
Please give contact details for payment:
  1. Personal Statement
Please detail in no more than 400 words why you want to complete the course. Ensure that you evidence that you are working for a service that can implement the learning.
  1. Disabilities and support needs
If you declare a disability this will not be a factor in the university’s decision as to whether or not to offer you a place. However it is important that Paladin knows if you have any specialist needs in order that we can provide you with appropriate support and facilities.
This information will remain strictly confidential
Do you consider yourself to have a disability? / Yes / ☐ / No / ☐
Type of disability
Specific learning disability
e.g. dyslexia, dyspraxia etc: / ☐ / Blind/partially sighted: / ☐ / Wheelchair user/mobility difficulty: / ☐
Mental health difficulty: / ☐ / Personal care support: / ☐ / Multiple disabilities: / ☐
Deaf/hearing impairment: / ☐ / Autistic spectrum disorder/Asperger syndrome : / ☐ / Unseen disability e.g. diabetes, cancer, epilepsy, asthma etc.: / ☐
Other: / ☐ / Please specify:
Nature of support required:
Do you agree that this information can (where applicable) be shared? / Yes / ☐ / No / ☐
  1. Equal Opportunities Monitoring

Ethnic origin
White / ☐ / Asian or Asian British – Indian / ☐ / Mixed – White and Black Caribbean / ☐
Black or black British – Caribbean / ☐ / Asian or Asian British – Pakistani / ☐ / Mixed – White and Black African / ☐
Black or black British – African / ☐ / Asian or Asian British – Bangladeshi / ☐ / Mixed – White and Asian / ☐
Other Black Background / ☐ / Chinese / ☐ / Other Mixed Background / ☐
Prefer not to say / ☐ / Other Asian Background / ☐ / Other Ethnic Background / ☐
Religion:
  1. Data protection statement

The information you supply on this form will be used by Paladin National Stalking Advocacy CIC in accordance with the Data Protection Act 1998 and other applicable legislation. Paladin will use the information to process your application and to provide any relevant further information by post, email or text.
If you meet the conditions and accept a place on the ISAC course, the information from your application form will be used to set up a student record that will be held by Paladin National Stalking Advocacy Service CIC.
Paladin will not share any of your information with third parties.
In order to prevent and detect fraud, we reserve the right to, or may be required to, share this information with external organisations such as the police, the Home Office, the Foreign Office, the UK Border Agency and local authorities.
  1. Declaration

I confirm that, to the best of my knowledge, the information given in this form is true, complete and accurate and no information requested or other material information has been omitted. I give my consent to the processing of my data by Paladin National Stalking Advocacy Service CIC.
I understand that any offer of a place on the above course is subject to my acceptance from Paladin National Stalking Advocacy Service CIC.
I confirm that I can understand, speak and write good English in order to understand the training materials and be able to fully participate in classroom exercises and complete assessment.
I confirm that I have adequate IT skills and have access to a current version of Microsoft Word, Microsoft Excel and the internet for the duration of the course.
I understand that any personal disclosure that takes place during the course shall remain within the training room except where such a disclosure relates to risks of harm to an individual or relates to child protection. Should the trainer identify that a disclosure relates to risk to life or child protection, Paladin National Stalking Advocacy Service CIC reserves the right to share information with the relevant authorities within legislative regulations.
I understand that if for any reason I cannot attend the course, I am required to give Paladin National Stalking Advocacy Service CIC written notice more than 30 days prior. If I cancel after this period; my employer is liable to pay the full course fee.
I accept that if I do not fully comply with these requirements, Paladin National Stalking Advocacy Service CIC reserves the right to cancel my application and I shall have no claim against Paladin National Stalking Advocacy Service CIC in relation to this application.
Applicant’s Signature
Date

Paladin – National Stalking Advocacy Services

Postal Address: PO BOX 72962, London, N7 1NZ
Charity Number: 1163801 Company Number: 09772287