Hackney Family Backup

Providing Community Support and Social Inclusion for Disabled Children and Young People

Short Break Carers Application Form

Please complete the form as fully as possible. All information will be kept strictly confidential to Hackney Family Backup.

If you prefer to apply by post, please print, complete and return this volunteer application form.

All fields marked with an asterisk * are compulsory.

1. Personal Information
Title:
Forename:*
Surname:*
Address:*
Postcode:
At current address since:*
*Please give at least one telephone number:*
Home telephone number:
Mobile telephone number:
Work telephone number:
Email address:
Where did you hear about HFBU?*
Gender:*	Male Female
Date of birth:*
Place of birth:
Nationality:*
How long lived in UK?*
Immigration status:
Are you disabled?	Yes No
If yes, nature of disability:
Religion:
Ethnicity:
Sexuality:
First language:
Other languages:

If applicable, please complete your address history for the last five years:

Address:

Dates(MM/YYYY):

From
To

From
To

From
To

From
To

2. Occupation

Please tick the relevant boxes to describe your present situation:

Employed Unemployed Student Part Time Full Time

If working or at college, what job or course are you doing?

3. Availability

When would you be available to care for a child / support a family? Please tick the appropriate boxes.
Please tick at least one box.

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
Morning
Afternoon
Evening

How often would you be able to offer support to a child / family? (e.g. twice a week):

4. Previous Experience

Please describe any previous experience of caring for a child and / or supporting families. Please include any job, voluntary work, or personal experience that you think is relevant.*

5. Accommodation and Household Members

If you are applying to be a homesitter, you do not need to complete section 5 - please go on to section 6. If you are applying to be a respite carer, you must complete all sections.

Tell us more about your home:

House Flat Bungalow Garden Stairs Lift

Number of bedrooms: Which floor:

Where would an additional child / young person sleep?

Please give details of other members of your household including children, lodgers, friends or significant others (N.B. all household members over the age of 16 will also require a police check):

Name	Male / Female	Date of Birth	Relationship to you

Do you have any pets? If so, please tell us their names and type / breed.

6. Additional Information

Have you or your partner ever applied to become a childminder or to foster or adopt a child?

Yes No

If yes, which agency or borough did you apply to?

Please give dates, details and outcome of your application:

Do you have your own transport?

Yes No

7. Consent to Statutory Checks

In order to protect children, we have to take out references, and conduct police, social services and medical checks on you. We will not carry out these checks until you have met with an HFBU staff member, and any information we receive about you will be kept confidentially and used fairly. Having previous convictions, involvement with social services, or health needs will not necessarily stop you from becoming a volunteer here.

References

Please give the names of two personal referees who you have known for two years or more who are not relatives:

	Referee 1	Referee 2
Name:*
Address:*
Tel no:*
How known to you:*

Please state your GP's name and address:

Name of GP:
Name of Surgery:*
Address:*
Telephone No:

STATEMENT: I accept that Hackney Family Backup has a responsibility to ensure the safety of children using the scheme. I therefore give my consent to Hackney Family Backup to carry out the above checks. I also give consent for the information on this form to be held and processed by Hackney Family Backup in written and/or computerised records, for the purposes of service provision and monitoring.

Signature (type name):* Date:*

©2007 HFBU - Registered Charity No: 1017015 - Company Registration No: 2422896
HFBU never make direct appeals to the public for funding. If you receive an e-mail requesting
financial assistance that you think might be from us please contact us immediately.