CONFIDENTIAL

Home-StartBolton

New Volunteer Application Form

If you have any queries regarding the completion of this form, please do not hesitate to telephoneour officefor assistance. The contact details are on the last page of this form.

Preferred Title: Ms/Miss/Mrs/Mr / First Name:
Second Name: / Last Name:
Address:
Town: / Postcode:
If you have been at this address for less than two years, please give your previous address / Mobile No:
E-Mail Address:
Home telephone no. (Land Line) / Work Telephone No:
Date of Birth: / Town of Birth:
Please Place x As Appropriate:
Asian or Asian British / Black or Black British / White
Indian / Caribbean / British
Pakistani / African / Irish
Bangladeshi
Any other Asian background Please specify: / Any other Black background Please specify: / Any other white background Please specify:
Chinese or other ethnic group / Mixed
Chinese / Any mixed background Please specify:
Other
References: Please give the name and contact details of two referees (not a relative by birth or by marriage ) who may be contacted by Home-Start Bolton.
Please inform your referees that we will be contacting them if your application to become a volunteer with Home-Start Bolton is successful.
Referee 1 / Referee 2
Name: / Name:
Address: / Address:
Postcode: / Postcode:
Contact telephone no: / Contact telephone no:
Languages spoken:
What is the minimum time you could offer to Home-Start Bolton as a volunteer on a regular weekly basis?
What type of transport would you use? / If by car –please indicate whether you have a current clean driving licence?
Please circle: / Yes/No
Please give details of any voluntary or paid work you have previously undertaken, particularly in relation to children and families:
Names of Your Children: / Age of Child: / Please advise us of information about your parenting experience:
Do you have any commitments that may affect your voluntary work with Home-Start Bolton?
Do you have any hobbies or leisure interests?
Do you have any skills or personal experiences that you feel may be relevant to your work as a volunteer for Home-Start Bolton?
How / where did you hear about Home-Start Bolton?
Please tell us why you feel you would you like to become a Home-Start Bolton Volunteer?
If you have any additionalinformation you wish to add, please do so below.
Home-Start Bolton volunteers are in the privileged position of visiting families in their own homes. This means that they will have contact with young children. Home-Start Bolton, therefore, has a responsibility to ensure that no one becomes a volunteer who would abuse this trust. Accordingly, please answer the questions below:
Have you had any personal contact with Social Services/Social Work Department or NSPCC/Children 1st in connection with children in your care? Please circle: / Yes/No
Do you have any medical condition (physical or mental) that could affect your work as a Home-Start Boltonvolunteer? Please circle: / Yes / No
Have you ever been dismissed from any paid or voluntary work? Please circle: / Yes/No
Have you ever been arrested or dealt with by the police for any type of criminal offence? Please circle: / Yes/No
Are there any matters outstanding which may lead to a criminal prosecution?
Please circle: / Yes/No
If you have answered‘Yes’ to any of the above questions, please give the details below:
PLEASE NOTE that if you do not declare existing and spent cautions or convictions, this may result in you not being selected to become a Home-Start Boltonvolunteer.However, if you declare these, it may still be possible for you to become a volunteer.

Declaration

It is Home-Startpolicy that we receive a signed copy of this application form. Therefore, please do not return this form by e-mail, unless it is a signed version that you have been able to scan in and forward. Thecompleted form can also be returned in the pre-paid envelope provided with this application pack.

Please read the declaration below and then sign and date the form before returning it to this office:-

I give permission for Home-Start Bolton to carry out criminal record checks at enhanced level with the appropriate agency. I understand that my National Insurance number may be required for identification purposes.

I declare that the information provided on this application form is true and complete and that I am not aware of any reason why I would be unsuitable to become a Home-Start Bolton volunteer.

I understand that Home-Start Bolton may hold personal information about me in records and on their computer, including sensitive information such as age, race, sex and disabilities that they will use for their monitoring purposes. I agree to them holding this information and understand that it may be shared with Home-StartUK for Quality Assurance purposes. I also understand that I may ask to see my records at any time.

Signed:
Date:

Home-Start Bolton Contact Information:Address:16 Wood Street, Bolton, BL1 1DY

Telephone: 01204 362786 / 381873 E:

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