PEER SUPPORT WORKER TRAINING APPLICATION

PERSONAL DETAILS

*Surname/Family Name / Home Telephone
*First Names / Mobile Telephone
Title / Work Telephone
Address / Email Address
UK National Insurance No
Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National? / YesNo
Please select the category that relates to your current immigration status. This status will be subject to checking before interview.
HSMP/Tier 1
Indefinite Leave to remain/enter
Post Graduate Doctors and Dentists
Dependant / Spouse visa / Clinical attachment visa
Student
Visitor
Working Holiday Visa/Tier 5 Youth Mobility / Work Permit/Tier 2
Tier 5 Temporary Worker
Refugee
Other, please specify below
Please supply details of any visa currently held, including number, start/expiry dates and details of any restrictions.
Visa No:
Start Date: (DD/MM/YY) / Expiry Date: (DD/MM/YY)
Details of Restriction:
Does your visa have a condition restricting employment or occupation in the UK? / YesNo
If you have a disability, do you require any reasonable adjustments to be made during the course application process, including interview? / YesNo
If yes, please supply details:
Please indicate if you have or have had any previous engagement with secondary mental health services: / Currently engaged  History of engagement
No previous engagement

Education & Professional QualificationsInclude in this section all the relevant qualifications. All qualifications disclosed will be subject to a satisfactory check.

Subject/Qualification / Place of Study / Grade/result / Year

TRAINING COURSES ATTENDED.Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking. Please also indicate subjects currently being studied.

Course Title / Training Provider / Duration / Date Completed

WORK/EMPLOYMENT HISTORY (including voluntary work). Please record below the details of your current or most recent employer

Employer Name
Address
Job Title / Grade
From Date / To Date (if applicable)
Reason for leaving (if applicable)
Description of your duties and responsibilities

PREVIOUS EMPLOYMENT. Please record below the details of your previous employment, beginning with the most recent first. If required, please provide additional information regarding your employment history on a separate sheet (or in the space provided on page 4).

Previous Employer 1

Employer Name
Address
Job Title / Grade
From Date / To Date (if applicable)
Reason for leaving (if applicable)
Description of your duties and responsibilities

SUPPORTING INFORMATION

In this section we want to know your reasons for applying to attend this training course. This can include relevant skills, knowledge, experience, voluntary activities and training etc. Please continue on a separate sheet if required (or in the space provided on page 4)

Please explain your experiences of living with a mental health condition
Why are you interested in undertaking this Peer Support Worker course?
What skills and attributes do you think you can bring to this course?
Additional Space: Please use this space to continue any answers.

DECLARATION

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent course enrolment. I understand that completion of this application form and, if successful, subsequent enrolment on the Peer Support programme, does not form an offer of employment (conditional or otherwise).

Enrolment onto the Peer Support Worker Programme requires undertaking a disclosure and barring service check . I consent that the organisation can undertake this check and that enrolment onto the Peer Support Worker programme will be conditional subject to satisfactory clearance.

I agree to the above declaration
Signature
Name / Date

Return to; Justine Brown, Recovery project, Room G17, Hellesdon Hospital, Drayton road, Norwich, NR6 5BE

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