Clwyd Special Riding Centre
Registered Charity Number 1118241

APPLICATION FORM FOR A NEW VOLUNTEER

PLEASE USE BLOCK CAPITALS THROUGHOUT AND RETURN TO THE CENTRE OFFICE ON COMPLETION.

CONFIDENTIAL INFORMATION FOR USE BY RELEVANT PERSONNEL ONLY.

You have a right of access to information held about you and other rights under the  Data Protection Act 1984.

Part A: YOUR DETAILS
First Name Surname Mr/Mrs/Miss
Any previous names by
which you have been known
Date of Birth
Address

 

Post Code
Telephone number: Home                                 Mobile
E-mail address

 

Part B: ADDITIONAL INFORMATION ABOUT YOU

(a) Experience

Horses/Ponies

 
Disabled Adults or Children

 

 

Other (e.g. First Aid Training, Nursing, Teaching, Secretarial Skills.)

 

 

(b) Fitness

Most helpers join a group to become involved with disabled adults or children, and horses and ponies. These activities require a degree of physical fitness. Other essential group activities (financial, administrative, secretarial) do not require the same level of fitness. Please describe any limitations on your ability to participate in group activities.

 

 

 

 

I confirm that I have read and agree to abide by the Centre's Child Protection Policy:
Signature
Date

(c) 1st Referee

First name Surname Mr/Mrs/Miss
Address

 

 
Telephone Number: Home                        Mobile
I am happy to recommend the applicant (whom I have known for……..years) as an RDA volunteer (preferably to be signed by someone other than a family member).
Signature
Date:

 

(d) 2nd Referee

First name Surname Mr/Mrs/Miss
Address

 

 
Telephone Number: Home                                 Mobile
I am happy to recommend the applicant (whom I have known for……..years) as an RDA volunteer (preferably to be signed by someone other than a family member).
Signature
Date:

 

Part C:

Have you ever been convicted of a criminal offence or been the subject of a caution, a ‘bound over order’ or a ‘civil action’ involving physical or sexual abuse or violence?

YES / NO (Please delete whichever is not applicable)

If YES, please give details:

 

You are advised that under the provisions of the Rehabilitation of Offenders Act 1974 (exemptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Amendment) 1986, you should declare all convictions, including ‘spent’ convictions.

Have you ever been subject to any disciplinary actions or sanctions relating to child abuse, sexual offences or violence?

YES / NO (Please delete whichever is not applicable)

If YES, please give details:

 

You are required to self-certify that you are not known to ANY Social Services as being an actual or potential risk to children, and that you have not been disqualified or prohibited from fostering children or had any rights or powers in respect of any child vested in or assumed by local authority, or had a child ordered to be removed from your care.

As part of the checking procedures, you are advised that the Group reserves the right to make reference to Local Authority Social Services Department and Police Records to verify information given on this form, when it is submitted or at any time in the future. It is the Centre’s policy to make random police checks and to take up all references.

Note. It is the duty of all Centre personnel, instructors and volunteers to report any charge or conviction involving children.

I consent to a criminal records check being made, confirm that all the information provided on this form is correct, and accept that failure to disclose information or subsequent failure to confirm to the Centre’s Child Protection Procedure may result in disciplinary action and possible suspension.
Signature
Date