childprotectionpolicy

Child Protection Committee

THE CATHOLIC DIOCESE OF RAPHOE

Diocese of Raphoe

Application Form for Adult Volunteers[i]

Confidential

Parish: _______________________________________________________________________

Surname: _______________________________________________________________________

First name: _______________________________________________________________________

Address: _______________________________________________________________________

_______________________________________________________________________

Tel. No: ____________________________ Mobile No: _______________________________

Email: _______________________________________________________________________

Date of Birth: ____________________________

Are you: (Please tick)

Employed _______ Unemployed _______ Student _______

Home maker _______ Retired _______ Other _______

Previous work experience:

___________________________________________________________________________________

Have you previously been involved in voluntary work? Yes _______No _______

If yes, please give details:

___________________________________________________________________________________

Why do you want to get involved with this parish activity / ministry?

___________________________________________________________________________________

Have you previously received any training for working with children? Yes _______No _______

If yes, please give details:

___________________________________________________________________________________

How much time can you commit to voluntary work? Please tick

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Morning
Afternoon
Evening

Do you have any spare time, hobbies, interests or activities?

___________________________________________________________________________________

Any other relevant information?

___________________________________________________________________________________

Is there any medical or other reason why you may be deemed unsuitable to work with young people?

Yes _______No _______ If yes, please give details:

___________________________________________________________________________________

Please provide the names and addresses of two people whom we could contact for a reference (not relatives):

Name ______________________________ Name ______________________________

Address ______________________________ Address ______________________________

______________________________ ______________________________

Tel. No: ______________________________ Tel. No: ______________________________

Email: ______________________________ Email: ______________________________

I declare that the above information is true and that I am fit to serve as a volunteer with this parish ministry/ activity. I agree to abide by and accept the terms and conditions of this participation

Signed ____________________________________________________

Date _____________________________

[i] Adapted from: Dept of Health and Children, Our Duty to Care: the Principles of Good Practice for the Protection of Children and Young People, Dublin : Stationery Office, 2001, pp 41–2.