Peer Mentor Application Form

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peer mentor application form

Personal Details

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

How did you hear about our Peer Mentor programme? *

We recognise that personal experience can offer a depth of understanding of the needs and aspirations of those with complex needs. Please complete the questions below with as much detail as possible.

Homelessness *

As a client As a volunteer As a worker Via relevant training

Substance Misuse *

As a client As a volunteer As a worker Via relevant training

Offending / criminal justice *

As a client As a volunteer As a worker Via relevant training

Mental Health Services *

As a client As a volunteer As a worker Via relevant training

Please explain why you would like to become a Peer Mentor *

What qualities and skills do you have that may be useful for this role? *

In order to match you with a suitable service user, we need to know more about you to enable you to build a successful mentoring relationship.

Please list any hobbies or interests that you have *

Supporting the Peer Mentor

We place great importance on recruiting people from all sections of the community and we are keen to support our volunteers at every stage. Please use this space to tell us about your own specific needs, if any. These could be related to physical or mental health, mobility, religion, culture or any other matter that you feel is important for us to know. We welcome applications from former service users. We appreciate that additional support might be required, please tell us about this.

The Support you would need: *

References

Please provide the full details of two people who can provide you with a reference. These may be former employers, places where you have volunteered, or people who know you in a professional capacity e.g. key hostel worker, support worker or social worker etc

Reference 1: (name, address, email, phone & your relationship *

Name Email Address Mobile Relationship

Reference 2: (name, address, email, phone & your relationship *

Name Email Address Mobile Relationship

Background Checks

The Whitechapel Centre welcomes applications from ex-offenders as part of its Equal Opportunities Policy. There are occasions where ex-offenders may be put into potentially vulnerable positions unless the persons background has been taken into consideration at the outset. For this reason we ask you to complete the following section:

Do you have any unspent convictions? *

Yes No

If the answer was YES, please give details of date(s) of offence(s) and sentence(s) *

I declare that the information given in this form is complete and accurate. I understand these details will be held in confidence by The Whitechapel Centre for the purposes of assessing this application, ongoing personnel administration and payroll administration (where applicable) in compliance with The Data Protection Act 1998.

Equal Opportunities

The Whitechapel Centre is committed to ensuring that applicants, volunteers and employees from all sections of the community are treated equally and not discriminated against on the grounds of gender, colour, race, nationality, marital status, religion or belief, sexual orientation, disability or age.

This form assists us in monitoring who is applying for employment with us, our adherence to equal opportunities best practice and our progress towards identifying any barriers to diversity among our workforce. We ask some questions regarding disability which may also assist us in determining whether any reasonable adjustments are necessary to facilitate your interview. [This form will be separated from your application on receipt, but if you are subsequently employed by us then we may retain it on your personnel file.]

We would be grateful if you would fill in this form and return it with your application. You are not obliged to answer all the questions but the more information you supply, the more effective our monitoring will be. All information supplied will be treated in the strictest confidence.

Thank you for your assistance.

What is your gender? (If you are currently undergoing the process of gender reassignment, please tick your future gender.) *

Male Female

How old are you? *

Date of Birth *

3. How would you describe your nationality and/or ethnicity? *

White - British - English, Scottish or Welsh British - Irish British - Other White background Black or Black British: Carribbean Black or Black British: African Black or Black British: Any other Black background Chinese Any other ethnic group Mixed Race: White & Black Caribbean Mixed Race: White & Black African Mixed Race: White & Asian Mixed Race: Any other mixed background Asian or Asian British: Indian Asian or Asian British: Pakistani Asian or Asian British: Bangladeshi Asian or Asian British: any other mixed background

How would you describe your religion? *

Can include "I am not religious" and "prefer not to say"

Do you consider yourself to have been homeless? *

Yes No

How would you describe your sexual orientation? *

Heterosexual Gay Bisexual Lesbian Other Prefer not to say

The Disability Discrimination Act 1995 (DDA) defines a disability as a "physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities". An effect is long-term if it has lasted, or is likely to last, over 12 months. Do you consider yourself to have a disability under the DDA? *

Yes Use to have a disability but have now recovered No Don't Know Prefer not to say

Please give details of any special adjustments required for work. *

If you answered "Yes" to the question above please give brief details of your condition and please indicate whether you may require any adjustments to enable you to attend and participate in an interview or to carry out any selection tests. Disabled applicants are invited to contact HR in confidence at any point during the recruitment process to discuss steps that could be taken to facilitate attendance and participation at an interview or in order to overcome any operational difficulties presented by the job. *

Rehabilitation of Offenders Act 1974 The Rehabilitation of Offenders Act 1974 allows people who have been convicted of certain criminal offences to regard their conviction as ‘spent’ after a period of years. This means that in general no reference need be made to the conviction or any circumstances relating to it. Because of the nature of work for which you are applying however, this post may be excepted from the provisions of the Act. You are therefore required not to withhold information about convictions which for other purpose are ‘spent’ under the provision of the Act. In the event of recruitment as a volunteer any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be considered only in relation to an applicant’s suitability to become a volunteer where such an exception is appropriate. *

For the purposes of compliance with the Data Protection Act 1998, I hereby confirm that by completing this form I give my consent to The Whitechapel Centre processing the data supplied above in connection with monitoring compliance with its equal opportunities obligations and policy. I also agree to the storage of this information on manual and computerised files. *

Please write your name here.

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The Whitechapel Centre
Langsdale Street
Liverpool
L3 8DT
Tel: 0151 207 7617

Charity Number: 1013060
Reg Co Number: 2623071

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