SPRINGFIELD COMMUNITY FLAT
53-54 Brocket House, Union Road, London SW8 2RE
Telephone: 020 7720 2699 Fax: 020 7627 2946
Staff/Volunteer Application Form – Confidential
Please complete in black ink or type
A Job Applied For
Position Title:
B Personal Information
Title: Ms. Miss Mrs. Mr. Other:
Surname: Forenames:
Previous name/ Other name you may be known by (if applicable):
National Insurance number:
Address:
Post Code:
Telephone No.: Day: Evening:
E mail address:
Date of Birth
May we contact you during the day? Yes No
Do you require a work permit? Yes No
Do you have a current driving licence? Yes No
Employers name and address / Dates of employment (with month/year) / Job Title and Salary / Reason for LeavingFrom / To
Title:
Salary:
Title:
Salary:
Title:
Salary:
Title:
Salary:
Title:
Salary:
Title:
Salary:
Title:
Salary:
Please continue on a separate A4 sheet if necessary.
School/ College(name and address) / Qualifications (including Grade / Dates
From: / Dates
To
Course / Dates – From: / Dates – To: / Qualifications
Please continue on a separate A4 sheet if necessary.
Please continue on a separate A4 sheet if necessary.
G. References
Please provide the following information for at least two referees. One of which should be your current or most recent employer. If you have not been employed before, please give details of teachers/ lecturers who know you well enough to comment on your ability to do the job. Friends or relatives must not be used.
.
Name: Current/ most recent employer Name: Preferably another employer
Job title: Job title:
Company Name Company Name
Address: Address:
Tel No. Tel No.
E-Mail Address: E-Mail Address:
Capacity Known: Capacity Known:
Current Manager Other Current Manager Other
Previous Manager Previous Manager
Please note, references will only be taken up after the interview process has been completed
Declaration for Workers and Volunteers.
Confidential
In the interests of the strategy of the children in this project, this section must be fully completed by all paid staff and volunteers over the age of 16 working on the Playscheme. The information given will be kept strictly confidential.
Section 1
Have you ever YES NO
(please tick)
(1) been convicted of any offences involving a child? [ ] [ ]
(2) had a child removed from your care by order of [ ] [ ]
any court or local authority?
(3) had registration as a chilminder refused or [ ] [ ]
cancelled?
(4) had your rights and duties with respect to any [ ] [ ]
child vested in a local authority?
(5) had a prohibition imposed on you at any time? [ ] [ ]
(6) been disqualified from acting as a foster parent? [ ] [ ]
If you have answered ‘yes’ to question (1), please give the details under
Section 2 – Declaration of Offences.
If you have answered yes to any of the questions, please give dates and circumstances here (please continue over the page if necessary):
I declare that to the best of my knowledge all the information given above is true and accurate.
Signature: Date:
Declaration of Offences
Section 2
Because volunteering/working on the Springfield Community Flat will involve working with children, under the Rehabilitation of Offenders Act 1974 (Exemption Order 1975) and the Children Act 1989, you are not entitiled to withhold information about any criminal convictions you might have, including those commited whilst a juvenile, which for other purposes are regarded as ‘spent’. Whilst we are committed to offering opportunities to ex-offenders, certain convictions may prohibit you from working at the Springfield Community Flat.
Please list below any convictions you have received for offences you have committed. Please give full details (date, offence, sentence), and include any cautions, bind-overs and spent convictions.
If you have none, please write “NONE”
Successful candidates will be asked to apply for an Enhanced Disclosure from the
Criminal Records Bureau – under Ofsted regulation.
Do you have an enhanced CRB disclosure? Yes No
If Yes please give the following details:
Disclosure Number: Issue Date:
I undertake to notify the Springfield Community Flat if I am subsequently convicted of committing any offence.
I declare that to the best of my knowledge all the information given above is true and accurate.
Signature: Date:
This form is separated from the main application form and will not be provided to the short-listing panel. Your answers will be treated in the strictest confidence and the information you provide will only be used for monitoring purposes. How you complete this form has no connection to the evaluation of your application in any way.
Surname: / Forenames:Date of Birth: / Sex: / o Male o Transgender
o Female
Position Title
ABOUT YOU. / What is your ethnic group? Please choose one selection from (a) to (e) and then tick the appropriate box to indicate your cultural background.(a) White / o British
o Irish
o Other. Please specify:
(b) Mixed / o White and black Caribbean
o White and black African
o White and Asian
o Other. Please specify:
(c) Asian or Asian British / o Indian
o Pakistani
o Bangladeshi
o Other. Please specify:
(d) Black or Black British / o Caribbean
o African
o Other. Please specify:
(e) Chinese or Other / o Chinese
o Other. Please specify:
ABOUT YOU.
/ Do you consider yourself disabled under the 1995 Disability Discrimination Act?Yes / o / No / o
ABOUT YOU – Optional. /
How would you describe your sexuality? – Optional. Please tick one box only.
Heterosexual / o / Gay / oBisexual / o / Lesbian / o
ABOUT YOU – Optional. / What is your faith / religion / belief? – Optional. Please tick one box only.
Agnostic / o / Humanist / o
Atheist / o / Jewish / o
Buddhist / o / Muslim / o
Christian / o / Sikh / o
Hindu / o / Other. Please specify
How did you find out about this vacancy? (Please give the name of the newspaper/ journal/website).
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