Full Name

Maiden or Former Name

Date of Birth

Contact Details

Home Phone/Email

Telephone - Day

Telephone - Evening

Email

Home Address

Street Line One:

Street Line Two:

Town/City:

Post Code

How long have you lived at the above address (in years)?

Previous Address

If less than 3 years please provide your previous address

How long there (in years)?

Previous Church

Name of previous church attended

Name of Minister

Previous Experience

Please give details of previous experience of looking after or working with children and/or young people, including details of training received

Reference

Please provide the following details of someone who knows you:

Name

Address

Telephone

Position/Relationship

Disclosures

Have you ever been convicted of a criminal offence, or are you at present the subject of criminal charges? See note below *
YesNo

If yes, please provide details

(N.B. The disclosure of an offence may be no bar to your appointment)

Consent

I consent to any relevant searches being carried out to ascertain my suitability to work with children or young people.

* Because of the nature of the work for which you are applying, this post is exempt from the provision of section 4 (ii) of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, and you are therefore not entitled to withhold information about convictions which for other purposes are 'spent' under the provisions of the Act and in the event of appointment, any failure to disclose such convictions could result in the withdrawal of approval to work with children and / or young people within the church.