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Personal details

Title

Mr Mrs Miss Ms Other

First Name *

Last Name *

Email Address *

Address line 1 *

Address line 2

Town *

County

Postcode *

Primary telephone number *

Secondary telephone number

Date of birth *

Do you require a permit to work in the UK? *

Yes No

Please give details of any restrictions, details of visa type and end date

National Insurance number *

Your experience & training

Are you currently... *

Employed Volunteer Student Other

Work history - 5 years

Company name *

Job title *

Start Date *

What does your role entail? *

Add previous work history *

Yes No

Previous work 2

Company name *

Job title *

Start Date *

End Date *

What does your role entail? *

Add previous work history

Yes No

Previous work 3

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 4

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 5

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 6

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 7

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 8

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 9

Company name

Job title

Start Date

End Date

What does your role entail?

Add previous work history

Yes No

Previous work 10

Company name

Job title

Start Date

End Date

What does your role entail?

Gap in work history

Please indicate and explain any gaps in employment since first leaving secondary education *

Include specific dates and be sure to account for all gaps

Relevant Qualifications, Education and Training

Any training including professional, vocational or job related *

Add More Qualifications, Education and Training *

Yes No

Any training including professional, vocational or job related including dates

Add More Qualifications, Education and Training

Yes No

Any training including professional, vocational or job related including dates

Add More Qualifications, Education and Training

Yes No

Any training including professional, vocational or job related including dates

Add More Qualifications, Education and Training

Yes No

Any training including professional, vocational or job related

Add More Qualifications, Education and Training

Yes No

Any training including professional, vocational or job related

Volunteer experience

Organisation name *

Start Date *

End Date *

What does your role entail? *

Add Volunteer Experience

Yes No

Organisation name

Start Date

End Date

What does your role entail?

Add Volunteer Experience

Yes No

Organisation name

Start Date

End Date

What does your role entail?

Add Volunteer Experience

Yes No

Organisation name

Start Date

End Date

What does your role entail?

Add Volunteer Experience

Yes No

Organisation name

Start Date

End Date

What does your role entail?

Add Volunteer Experience

Yes No

Organisation name

Start Date

End Date

What does your role entail?

Volunteering

What are the main reasons that you want to be a mentor and how do you feel you will benefit from the experience? *

In what ways do you feel you could help a young person having a tough time? *

Describe any additional skills, experience & interests that you would be willing to share with a young person you mentor *

Are you able to commit to the role for one year? *

Yes No

Are you able to commit to core training (one weekend), ongoing training and review meetings (no more than once a month)? *

Yes No

Can you drive? *

Yes No

Do you have access to a car?

Yes No

How did you hear about Mentoring Plus *

Please be specific

References

Please give full details, in the boxes below, of two referees. If possible please include your present or past employer or school or college. We do not accept family members or friends as referees

Reference One

Name *

Address *

Position Held *

Email address *

Contact Telephone No *

How are they known to you? *

How long have you known them? *

Reference Two

Name *

Address *

Position Held *

Email address *

Contact Telephone No *

How are they known to you? *

How long have you known them? *

Declaration

Safeguarding *

I declare that the information I have given on this form is complete and accurate I am not barred or disqualified from working with vulnerable groups, children or young people I am not subject to any sanctions or conditions on my employment imposed by the Independent Safeguarding Authority, Secretary of State or other regulatory body

Data *

I understand that you will securely store and process the data included in this application and any other data I and my referees may supply in the course of this application, for the purposes of safer volunteer recruitment I consent to my data being held and processed by Mentoring Plus within the terms of their Privacy Notice I give consent to photographs/video of myself being used for Mentoring Plus charitable purposes

General *

I understand that to knowingly give false information or to leave out any relevant information could result in the withdrawal of any offer of appointment, or my dismissal at any time in the future, and possible criminal prosecution

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01225 429694

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