mentor application pack

together we canstamp out the stigma

of depression

...one word at a time

1© The Blurt Foundation CIC -Registered Company in England and Wales. No 07628600.

Please fill out the Mentor Questionnaire on Page 2 &Your details on Page 3, then email back to: jayne@blurtitout.org

Then print out the CRB declaration form on Page 4fill it out, sign, then send back to:Jayne Hardy, The Blurt Foundation

Devonport Guildhall, Ker Street, Plymouth, Devon PL1 4EL

Don’t forget to include your chosen forms of identification.Use the checklist on Page 5 at the end of this document.

Please do not scan in documents, we do require the originals.Don’t worry we will send them back to you.

If mentoring isn’t for you, but you would still like to help,just drop us an email as there are still plenty of ways to get involved.

mentor questionnaire

Why do you want to be a mentor for Blurt?

What qualities do you think you have which will make a good mentor?

Can you tell us a bit about your experiences of Depression?

How much time could you give to being a mentor?

2© The Blurt Foundation CIC -Registered Company in England and Wales. No 07628600.

your details

3© The Blurt Foundation CIC -Registered Company in England and Wales. No 07628600.

Full Name, including middle name: DOB:Country of birth: Town/city of birth:Title Mr/Mrs/Miss/Ms:Marital Status: Date of marriage:Maiden name:Have you been known by any other names?National Insurance Number:Email: Phone:

Current full address: Postcode:Date moved to this address:

If you have lived at the above address for less than 3 years, please give details of your previous address: Postcode:Dates at this address:

If you lived at this address for less than 3 years, please also give details of your previous address: Postcode:Dates at this address:Please provide the names and contact details of two referees, not relatives, who we may ask for references. Please note: a referee can be an employer, a tutor at college, a minister of religion or any reputable person.Name: How do you know this person?Address: Postcode:Email: Phone:

Name: How do you know this person?Address: Postcode:Email: Phone:

Full Name, including middle name: DOB:Country of birth: Town/city of birth:Title Mr/Mrs/Miss/Ms:Marital Status: Date of marriage:Maiden name:Have you been known by any other names?National Insurance Number:Email: Phone:

Current full address: Postcode:Date moved to this address:

If you have lived at the above address for less than 3 years, please give details of your previous address: Postcode:Dates at this address:

If you lived at this address for less than 3 years, please also give details of your previous address: Postcode:Dates at this address:Please provide the names and contact details of two referees, not relatives, who we may ask for references. Please note: a referee can be an employer, a tutor at college, a minister of religion or any reputable person.Name: How do you know this person?Address: Postcode:Email: Phone:

Name: How do you know this person?Address: Postcode:Email: Phone:

crb check

4© The Blurt Foundation CIC -Registered Company in England and Wales. No 07628600.

The following questions are subject to the provisions of the Rehabilitation of Offenders Act 1974. You are legally entitled to withhold information about

convictions which may, under the act, be regarded as spent.

Do you have any criminal convictions? If yes, please give full details below of the nature of the offence, court and date of convictions and sentence:

Are you subject to any outstanding criminal proceedings that may result in a conviction?If yes, please give details below:

Declaration

Name in full:

Signature:

Date:

*Disclosure (Criminal Records Check). Please note that should you be accepted as a volunteer, The Blurt Foundation may require you to undergo a criminal records check with the Criminal Records Bureau (CRB).

Please note that under the terms of the Data Protection Act 1998, The Blurt Foundation has to inform you that the information you have provided on this application form will not be disclosed to any other organisation.

CRB IdentificationChecklist Form

5© The Blurt Foundation CIC -Registered Company in England and Wales. No 07628600.

There are two options: Provide 1 source of ID from Group 1 along with 2 from Group 2

ORProvide 5 sources of ID from Group 2

Group 1Passport

UK driving LicenceHM Forces ID Card (UK)

Adoption Certificate (UK)EU National Identity Photo Card

UK Birth CertificateUK Firearms Licence

Group 2Marriage/Civil Partnership certificateBirth CertificateP45/P60 Statement (UK) **Bank/Building Society Statement *Utility Bill *TV Licence **Credit Card Statement *Store Card Statement *Mortgage Statement **Valid Insurance Certificate **Council Tax Statement (UK) **Document from Local/Central Government *CRB Disclosure Certificate **Asylum Registration Card

Financial Statement **Valid Vehicle Registration DocumentMail Order Catalogue Statement *Court Claim Form (UK) **Exam CertificateAddressed Payslip *National Insurance Card (UK)NHS Card (UK)Benefit Statement *Certificate of British Nationality (UK) Work Permit/Visa (UK) **Connexions Card (UK)Letter from a Head Teacher **Document must be less than 3 months old**Issued within the past 12 months