1. Programme Details
Programme Title Mode of study* Academic Year
2. Personal Details
* Surname/Family Name (BLOCK CAPITALS)
* First/Given Name (BLOCK CAPITALS)
* Title (e.g. Mr Mrs Miss Mrs etc.)
Preferred name
Previous Surname, if changed
* Date of Birth (DD/MM/YY)
* Gender (M for Male or F for Female)
* Country of Birth
* Country of Residence
* Nationality
3. Correspondence Address
* Address Line 1 (BLOCK CAPITALS)
* Address Line 2
* Town
County
* Postcode
* Country
* Telephone Number
(including international and national codes as appropriate)
* Alternative Telephone Number (if different)
* Email Address
4. Education / Qualifications
School, College or University No.1
* From (Month/Year) * To (Month/Year)
* Examinations or assessments taken for which results are known (including those failed)
(example: History / BSc / June 2004 / 2:2 / Full time)
School, College or University No.2
* From (Month/Year) * To (Month/Year)
* Examinations or assessments taken for which results are known (including those failed)
(example: History / BSc / June 2004 / 2:2 / Full time)
School, College or University No.3
* From (Month/Year) * To (Month/Year)
* Examinations or assessments taken for which results are known (including those failed)
(example: History / BSc / June 2004 / 2:2 / Full time)
5. Qualifications not yet completed or certificated
Examination (s) No.1
School, College or University
Date exam(s) set or scheduled(Month/Year)
Date result(s) published(Month/Year)
Examinations or assessments for which results are not yet known (subject / level / mode of attendance)
Examination (s) No.2
School, College or University
Date exam(s) set or scheduled(Month/Year)
Date result(s) published(Month/Year)
Examinations or assessments for which results are not yet known (subject / level / mode of attendance)
Examination (s) No.3
School, College or University
Date exam(s) set or scheduled(Month/Year)
Date result(s) published(Month/Year)
Examinations or assessments for which results are not yet known (subject / level / mode of attendance)
6. English Language
* Details of English language qualifications
Were all the qualifications you are telling us about in this application assessed completely or partly in English? If not please state which one/s were assessed.
7. Employment
Employer No.1
Name of Employer
From(Month/Year) To(Month/Year)
Nature of your job
Employer No.2
Name of Employer
From(Month/Year) To(Month/Year)
Nature of your job
Employer No.3
Name of Employer
From(Month/Year) To(Month/Year)
Nature of your job
8. Personal Statement
* Statement
Please enter your Personal Statement here:
9. Availability for interview
* Please state when you would NOT be available for interview:
10. Criminal Conviction
* Do you have connections in your personal life with any individual (relative, household member or friend) who could present a risk to children or who has been convicted of a criminal offence which would deem them unsuitable to work with children?(Please answer Yes or No)
* Have you, as an adult, had involvement with a local authority, in relation to care proceedings or child protection proceedings in your family?(Please answer Yes or No)
* Have you ever been arrested, cautioned for or convicted of a criminal offence or other offence which would show in a CRB enhanced disclosure?(Please answer Yes or No)
If YES, please give details and an explanation of the offence and sentence or penalty imposed (including suspended sentences, warnings etc) in a separate file marked ‘confidential’ including an explanation of how you have consequently demonstrated you are a suitable person to work directly with children.
As the voluntary placement will involve access to children, the placement is exempt from the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 1986 and you will be required to undertake an Enhanced Disclosure from the Criminal Records Bureau CRB which will show all records. Please contact us if you would like further information.
Any placement offered would be conditional on the receipt of an enhanced CRB which satisfies the criteria of Place2Be. A copy of the CRB Code of Practice is available on the CRB website.
11. Referees
Please fill in the name, address and contact details for each referee in the boxes below.
First Referee
* Name
* Relationship (eg. employer, tutor or friend)
Address
* Telephone number * Email address
Second Referee
* Name
* Relationship (eg. employer, tutor or friend)
Address
* Telephone number * Email address
12. Additional Needs
Do you have any disabilities or special educational needs?
Please give further details of any disability or special needs
13. Additional Information
* How did you hear about the Programme? Please give details.
14. Data Protection
* You may use my data in this way (I Agree/I Do Not Agree)
Please also note that under the terms of the 1998 Data Protection Act you may withdraw your consent to us using your data in this way at any future point. If you would like us to keep you informed at present, but change your mind later please email asking for your record to be amended accordingly.
15. Declarations
* I agree to these declarations (Signature)
If invited for an interview, you will be asked to supply proof of the information submitted, or to otherwise confirm the details of this application, in person. This will include providing proof of identity.
Please return this form to Place2Be. You can send this form as an email attachment, or you can print out and send it by post or fax.
Please ensure that you enclose two references with your application (if you fax or email your application please ensure that your references follow by post).
Place2Be Professional Qualifications Team
Email:
Tel: +44 (0)20 7923 5558
Fax: +44 (0)20 7833 8083
Address:
The Place2Be
Training Team
13/14 Angel Gate
326 City Road
London
EC1V 2PT
Ensuring equality in recruitment and selection for paid and unpaid positions and training courses
The Equality and Human Rights Commission strongly recommend that monitoring is effectively carried out and Place2Be fully supports this.
Place2Be aims to ensure that no job or course applicant receives less favourable treatment on the grounds of race, colour, gender orientation, nationality, religion, ethnic or national origin, age, gender, gender reassignment or marital status, sexual orientation or disability. Selection criteria and procedures are regularly reviewed to ensure that individuals are treated on the basis of their relevant merits and abilities. All workers and students will be given equal opportunity and access to training to enable them to progress both within and outside the organisation. This organisation is committed to a programme of action to make this policy effective and will bring it to the attention of all workers and students.
In order to enable us to successfully monitor and assess whether equality of opportunity is being achieved, please complete this form and return it with your application form.
Rehabilitation of Offenders Act 1974. As Place2Be meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, applicants offered employment/training will be subject to a criminal record check from the Criminal Records Bureau before appointment or placement is confirmed. This will include details of cautions, reprimands or final warnings as well as convictions.
Completing this form is voluntary. However, it will enable us to carry out our monitoring policy effectively. The information will be separated from your application as soon as it is received. It will not be passed on to anyone involved in short-listing or appointment to this course.
______
Course Applied For______
Are you?
□ Male□ Female
Date of Birth: ______
The Disability DiscriminationAct 1995 defines a disabled person as someone with a physical or mental illness or impairment which has a substantial and longterm adverse effect on his or her ability to carry out daytoday activities.
Do you consider yourself to have a disability which may affect your employment/placement?
If Yes, Please provide details:
What is your ethnic group?
Please choose one section from (a) to (e) and then put a cross or tick in the appropriate box to indicate your cultural background (as recommended by the Commission for Racial Equality).
(a) White(d) Black or Black British
□ British□ Caribbean
□ English□ African
□ Scottish□ Any other Black
□ Welsh background, please state
□ Irish ______
□ Any other White background, please state
______
(b) Mixed(e) Chinese or Chinese British or other ethnic group
□ White and Black Caribbean
□ White and Black African□ Chinese
□ White and Asian□Any other, please state
□ Any other Mixed background,______
______
(c) Asian or Asian British
□ Indian
□ Pakistani
□ Bangladeshi
□ Any other Asian background, please state
______
Please print this page separately from the above application.