Volunteer Mentor Application Form

Private and Confidential

Personal Details
Title
Forename(s)		Surname
Date of Birth	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992	Nationality
Faith (if none, please state)
Contact Details
Address		Postcode
Telephone Home		Telephone Work
Mobile		Email
Emergency Contact
Name		Telephone
Relationship
Employment and Education Details
Relevant Qualifications and Training
Occupation
Employment Status	Full Time Part Time Unemployed
Further Details
Do you....
Own a car?	Yes No	Possess a current CRB (Criminal Records Bureau) certificate?	Yes No
Have a current driving license	Yes No	Currently work in prisons (paid or unpaid)	Yes No
References Please give the names of two people whom we will approach for a reference: One should be a character reference from someone you have known for over 12 months and one should be from a previous employer. PLEASE INFORM YOUR REFEREE THAT WE WILL BE CONTACTING THEM.
Character Referee
Name		Address
Telephone		Email
Employer Reference
Name		Address
Telephone		Email
Declarations Disclosure of criminal records, Orders of Civil Courts, on probation, charged with an offence pending and other conduct. If you answer YES to any of the questions below, please give full details.
Have you ever been convicted of a criminal offence (including any spent convictions under the Rehabilitation of Offenders Act, 1974), or been cautioned by the Police or bound over to keep the peace?			Yes No
Have you ever been held liable by a Court for a civil wrong or had an order made against you by a matrimonial or family court?			Yes No
Has your conduct ever caused or been likely to cause harm** to a child* or put a child* at risk, or, to your knowledge, has it ever been alleged that your conduct has resulted in any of those things?			Yes No
*'child' for this purpose means anyone under the age of 18, '**harm' includes ill-treatment of any kind (including sexual abuse) or impairment of physical or mental health or development. This question relates to any conduct, whether as a paid employee, a voluntary worker, acting in a parental capacity or otherwise.
We would like to know why you think you would be suitable in this role. Please take time to answer the following questions, in the best way you can:
Have you any experience of working with people in, or coming out of, prison and if so, what experience do you have?
What support do you think you could offer people coming out of prison?
Tell us about a difficult situation that you have had and how you dealt with it.
Tell us briefly, why you want to become a volunteer mentor for Futures Unlocked?
By submitting this form, you confirm that the information you have supplied is correct, to the best of your knowledge and belief.
Health & Wellbeing Questionnaire This questionnaire is for insurance purposes only. Please be aware that the answers you give will not affect your application. Any false information will be dealt with accordingly.
1. Do you have any medical issues we should be aware of?		2. Are you currently on any medication?
	Yes No		Yes No
Details (if yes):		Details (if yes):
3. Do you have any allergies?		4. Do you have any learning difficulties?
	Yes No		Yes No
Details (if yes):		Details (if yes):
5. Do you have a history of substance abuse?		6. Are you comfortable travelling to meet the client on your own?
	Yes No		Yes No
Details (if yes):
MONITORING SHEET Futures Unlocked operates policies designed to ensure that all applicants receive equal treatment, regardless of their ethnic origin, se or physical disability. To help the Board monitor the implementation of these policies, will you please provide the following information which will be used solely for monitoring purposes.
Gender	Male Female	Cultural/Ethnic Origin	Please select African Afro-Carribean Asian-Carribean Bangladeshi British Asian British Black British White Black Other Chinese Indian Other
Do you consider yourself to have a disability?		Your age	Please select 16-18 19-35 36-49 50-59 60-65 65+
	Yes No
Details (if yes):

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