Council
Please complete in black ink or typescript as this form may be photocopied. /
Application Form
For the role of: Breakthrough Mentor
PERSONAL DETAILS SECTION 1
Surname: / Title by which you wish to be referred:
(Mr, Mrs, Miss, Ms, etc)
Forename(s):
Address:
Postcode: / Home Telephone:
Daytime Telephone:
Mobile Number:
E-mail address:
Date of Birth: / National Insurance Number:
RELEVANT QUALIFICATIONS/TRAINING COURSES SECTION 2
Qualification / Course Title / Duration of Course
(if applicable) / Date Obtained
In order to protect the young people and vulnerable adults we support, it is very important that we learn about what you have been doing e.g. school, raising a family, in a job or looking for a job. Wherever possible tell us the dates involved (month and year) e.g. PatchwayCommunitySchool Sept 2000 – June 2005
Please tell us which schools you attended (including month and year)
Describe briefly any previous work experience that you have had [including dates). This could be paid employment, work experience,voluntary or community work. If you have any gaps in your work experience could you also tell us about what you were doing and the dates (including month and year)BACKGROUND INFORMATION SECTION 3
Do you have any previous experience of Mentoring? Yes No
If Yes, please state the organisation that you were a mentor for and the activity you were involved in?
What qualities and skills do you possess that would make you an effective mentor?
The Breakthrough Project is an activity based mentoring project (eg sport, gardening, dog walking, model making): Please list any activities that you have a particular interest or experience in.
Please list any activities you would definitely not want to be involved in (e.g. if you don’t like heights, or can’t swim etc):
Please provide additional information which you consider relevant to your application. Include details of relevant professional and/or personal experience and your reasons for applying to the project. You may continue on an additional sheet if necessary.
What Gender would you prefer your Mentee to be?
Male Female Either
On which days and when are you available to mentor?
MON / TUE / WED / THUR / FRI / SAT / SUN
MORNING
AFTERNOON
EVENING
SUPPLEMENTARY INFORMATION SECTION 4
Do you hold a current full driver’s licence? YES NO
Do you have regular use of a vehicle? YES NO
Disclosure Check
As this post is subject to an enhanced Disclosure and Barring Service (DBS) Check (previously known as CRB check, you will be required to complete a DBS form, show proof of identity and various other documents.
Convictions
Any job/volunteer role that involves working with Young People or Vulnerable Adults is exempt from the Rehabilitation of Offenders Act 1974. This means that we are allowed to ask you to give us details of any convictions you may have had.
Please tell us about any Convictions you have (including month and year)
NAME AND ADDRESS OF TWO REFEREES SECTION 5
Please give a minimum of two referees who we can contact to ensure that you are a suitable person to work with young people or vulnerable adults. These should be people who know you well, but to whom you are not related, and who will supply character references. The references should at least cover the last 3 years. Please continue on extra sheets if necessary.
Reference 1 / Reference 2
Name and title
Address
Postcode
e-mail:
Position/
Relationship e.g. employer, teacher, colleague
DECLARATION SECTION 6
I certify that, to the best of my belief, the information I have provided is true, and I understand that any false information or failure to disclose criminal convictions may result in the termination of working arrangements with South Gloucestershire Council.
Data Protection Act 1998
I hereby give my consent for personal information provided as part of this application to be held on computer or other relevant filing systems in accordance with the Data Protection Act 1998Signed: Date:
Name: