Volunteer Application Form 1 Your details2 Emergency contacts3 References4 About you5 Monitoring information6 Disclaimer Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code Email* Telephone number*Date of birth* Date Format: DD slash MM slash YYYY Place of birth*Age of your children Emergency Contact #1 First Last Telephone numberEmergency Contact #2 First Last Telephone number Reference #1Please provide the name, address and postcode of a person who has known you for at least 2 years (not a relative, preferably an employer) who can provide Home-Start Trafford, Salford & Wigan with a reference for you. Please make sure that you ask permission and ensure they are willing to provide a written reference before providing details. Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code Email PhoneHow long have you known this person?*What is your relationship with this person?*Reference #2Please provide the name, address and postcode of a person who has known you for at least 2 years (not a relative, preferably an employer) who can provide Home-Start Trafford, Salford & Wigan with a reference for you. Please make sure that you ask permission and ensure they are willing to provide a written reference before providing details. Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code Email PhoneHow long have you known this person?*What is your relationship with this person?* Are you able to give a minimum time commitment of 3 hrs per week, as a Volunteer, to Home-Start Trafford and Salford, on a regular weekly basis?*YesNoPlease give details of any voluntary/paid work you have undertaken, particularly with children and families:*Please tell us about your parenting experience: (both the enjoyable and challenging aspects)*Have you any commitments which could affect your tasks as a volunteer with Home-Start Trafford and Salford e.g. employment/training course/child care commitments etc?*Could you tell us about your hobbies and interests?*Have you any skills/experience or qualifications which may be relevant to your tasks as a homevisiting volunteer?*Why would you like to become a home-visiting volunteer?*Have you had any connection with any other Home-Start Scheme?*YesNoIf yes, please give details including name of the scheme, your role (trustee, volunteer, paid worker) and the dates that you were involved:*Is there any other information you would like to add? * I understand that Home-Start Trafford and Salford may hold information about me in paper records and on their computer, including sensitive information such as age, race, religion, sex and disability that may be used for monitoring purposes. * I agree to them holding this information and understand that it may be shared with HomeStart UK for Quality Assurance purposes. * I understand that I may ask to see my records at any time. Ethnicity*IndianPakistaniBangladeshiCaribbeanAfricanOther Black BackgroundEnglish/Scottish/Welsh/Northern IrishIrishGypsy or Irish TravellerOther White Background:Other Mixed BackgroundArabAny other ethnic groupReligion*ChristianHinduJewishBuddhistMuslimSikhOtherNot givenGender*MaleFemaleTransgenderNot givenSexuality*HeterosexualLesbian/Gay/BisexualNot given Home-Start Trafford, Salford & Wigan is committed to safe recruitment practice as an important part of safeguarding and protecting children and adults. As volunteers are in a privileged position visiting families in their own homes and usually have regular contact with young children, Home-Start Trafford, Salford & Wigan has a responsibility to ensure that no-one becomes a volunteer who would misuse this trust. Therefore, it is essential that you complete and sign this form. Name* First Last Have you had any personal contact with Social Services / NSPCC / Children 1st, in connection with a child or children in your care?*YesNoDo you have any medical condition (physical or mental) that could affect your tasks as a home-visiting volunteer?*YesNoDo you have any convictions, cautions, reprimands, or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)**YesNoHave you ever been dismissed from any paid or voluntary work?*YesNoAre there any matters outstanding that may lead to criminal prosecution?*YesNo*The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers, and cannot be taken in account. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service website.If you have answered yes to any question above please give details including : dates, type of offence, connection with Social Services, medical condition etc*If you do not declare existing or spent cautions or convictions you may not be selected, however if you declare any of the above it may still be possible to become a volunteer.Having a criminal record will not necessarily bar you from volunteering with Home-Start Trafford, Salford & Wigan. Home-Start Trafford, Salford & Wigan complies with the Disclosure and Barring Service (DBS) Code of Practice and has its own policy regarding the questions above. Further investigations may take place via a Trustee sub-committee, who will make the decision about an applicant’s suitability before they are accepted onto the volunteers’ training/preparation course.* I give permission for the Scheme Manager, Co-ordinators or Administrator of Home-Start Trafford, Salford & Wigan to apply to the DBS for an Enhanced Disclosure and any other checks with the Department of Health, Social Services or Department for Education. I understand that my National Insurance Number will be required. * I know of no reason why I would be unsuitable to become a home-visiting volunteer with Home-Start Trafford, Salford & Wigan. Signature of VolunteerTyped will do if online Signature of Co-ordinator Please sign here ............................................................................................................................... This iframe contains the logic required to handle Ajax powered Gravity Forms.