APPLICANT CODE
Independent Visitors Volunteer Application form
Position applying for:Family Name: Forenames:
Previous name:
Other ‘known by’ names:
/ Date of birth:
Postal address including postcode:
Length of time at this address:
Email address: / National Insurance number:
Telephone numbers
Home Mobile Work (if convenient)
Please tick:
Are you a Member of the Local Authority or employee of Lincolnshire Children’s Services? Yes No
Are there any restrictions to you taking up a volunteering role in the UK? Yes No
If yes, please provide details
Are you registered as disabled? Yes No
Are you married? Yes No
If yes please give date and place of marriage
Do you have a registered civil partnership Yes No
If yes please give date and place of registration
Are you living with a partner? Yes No
If yes please give the date on which you set up a household together
Is your partner a Member of the Local Authority or employee of Lincolnshire Children’s Services?
Yes No
Are you separated, divorced or have you dissolved a civil partnership? Yes No
If so please give date and name of partner
Have you previously set up home with a partner? Yes No
If so please give date when this ended and name of partner
Please provide the following information:
Gender
Nationality
Ethnic Origin
Primary language spoken
Other languages spoken
Other forms of communication you have been trained in e.g. British Sign Language or Makaton
Religion or faith group
Practicing or non-practicing
Current occupation if any
Current employer if any
Date started
Current hours of work
Study and Employment history (Please list any other employment in date order). Please ensure that all dates are covered including any gaps in employment or study. (Please continue on a separate sheet if necessary).
Interests and Experience including any Voluntary work
List below any community activities, membership in clubs, faith groups and other organisations, including any voluntary work you have previously done
List any hobbies or special interests
Availability for Volunteering (please indicate the hours you would be available to volunteer)
Morning / Afternoon / Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Supporting statement
Please say why you think you are suitable for this voluntary work.
You should tell us anything relevant about yourself, particularly in relation to knowledge, understanding and experience of children/young people and why you want to become an Independent Visitor. Please provide clear evidence of your suitability and a clear statement about your flexibility and availability, both to carry out the role and to be available in the long term, making an open ended commitment. (You may attach a typewritten sheet instead of this page, or add fuller notes if needed. Please ensure that you use only A4 paper and that your name and signature is on each page attached).
Health
Do you have a physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? (please tick) Yes No
Please specify any special arrangements associated with any impairment
Please specify any special arrangements you will need to attend the interviews and /or training
Please list any diseases, disorders, allergies, muscular or musculoskeletal injuries from which you have suffered or do suffer.
Please detail any form of medicine, drugs or treatment you are currently and/or regularly receiving.
Other information
Have you a current full driving licence?
Yes No
Do you have access to a car to visit a child? (your insurers would need to be informed about the role, this would normally involve you having cover for Personal Business use) / If yes, please give details of any endorsements.
If appointed, when could you start?
Rehabilitation of offenders
The voluntary post for which you are applying is exempt from the provisions of the Rehabilitation of Offenders Act (1974). When answering the following questions you must therefore disclose any criminal convictions, even those that may be considered ‘spent’ for other purposes.
Rehabilitation of Offenders Act 1974 (Exceptions Order 1975).
Have you ever been found guilty of committing an offence or of having done the act or made the omission with which you were charged in any proceedings bought by a local authority in relation to the care of a person under 18 years old? / Yes No
Have you ever been convicted of an offence in any criminal proceeding in any court in any country?
(for motoring offences, please answer ‘yes’ only if it resulted in disqualification). / Yes No
Have you ever been found guilty of violent, cruel, indecent or dishonest behaviour in any service disciplinary proceedings? / Yes No
Have you ever been convicted of any offences under the 1958 Adoption Act as amended by the 1975 and 1989 Children Act? / Yes No
Are you aware that there are any current police enquiries or pending prosecutions in relation to you? / Yes No
If you have answered ‘yes’ to any of these questions please give details, continuing on a separate sheet if necessary
Applicants for all Coram Voice posts will be asked to complete a DBS form at interview. In the event that you are successful in your application, Coram Voice will apply for an Enhanced DBS check. This will include details of cautions, reprimands or final warnings as well as convictions.
Failure to disclose any criminal conviction will automatically disqualify you from the recruitment process. However, a previous criminal conviction which you have declared will not necessarily be a bar to obtaining the position applied for.
Are you on the POCA (Protection of Children Act) list? Yes No
References
Please give names and addresses of 3 people we may approach for a reference. One of them should be your present or most recent employer or tutor if studying. Another should have known you for at least 2 years and be able to comment on your experience with children and young people. They should not be related to you.
Coram Voice reserves the right to contact any previous employer. We may make contact by telephone with any of your referees. In any event, we will not make an appointment until satisfactory references have been received.
First referee
Name
Address
Postcode
Telephone number Email
How do you know him/her?
May we take up the reference before interview?
Second referee
Name
Address
Postcode
Telephone number Email
How do you know him/her?
May we take up the reference before interview?
Third referee
Name
Address
Postcode
Telephone number Email
How do you know him/her?
May we take up the reference before interview?
Declaration
I confirm that the above information is complete and correct and that any untrue or misleading information will give Coram Voice the right to terminate any voluntary work offered.
I agree that the organisation reserves the right to require me to undergo a medical examination. (Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor). I agree that this information will be retained in my personnel file during my time as a volunteer and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection Act.
Signed: Date:
Please return your completed form to
Coram Voice is the working name of Voice for the Child in Care
Registered Charity Number 1046207 Company Reg. No. 3050826