Student / Work Placement Application Form All information contained in this form will be treated as strictly confidential. Please complete all sections of the form to the best of your ability. The more information we have the easier it is to select the right person to place with us. If you require assistance in completing this form please contact the Volunteers Office in Depaul Ireland (+353 1) 633 9226. Please type or complete in block capitals and ensure that you sign the form on the last sheet.
Your contact details Forename
Surname
Are you over 18 years of age? Yes
Proposed start date
Gender
Proposed end date
Email Address
No
Full postal address
Telephone (home)
Telephone (mobile)
Telephone (work)
Education and training If you would like to provide details of secondary schools, colleges, universities or Institute of Further Education attended, please do so below: Period: from / to Name / nature of establishment Qualifications and name of course completed
Non Formal Training Please list any other relevant qualifications or non‐certified courses:
Employment If you would like to provide details of your work experience to date, please do so below: Period: from / to Name and Address of Employer Position Held and summary of duties
Further Study Information Please help us to place you effectively by completing the following information about yourself. Please list the main subjects / topics on your course
What are the objectives of your placement?
What do you think you can bring to the placement in terms of skills, activities projects etc.?
How do you feel your placement would benefit Depaul Ireland and its service users?
Why have you decided to take a placement with Depaul Ireland?
Interest Please read the project describitions and indicate which project you would like your placement to be in
Availability Please tick when you could be available for placement (if a block placement state the dates) Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Morning Afternoon Evening
Sundays
Referees Please provide the contact details of two referees who are in a position to assess your skill, knowledge and aptitude for placement with Depaul Ireland. References will only be accepted from those that know you in a professional capacity and therefore can’t be accepted from family or friends. Please complete all details. First referee Second referee Period of Employment / Study volunteering / relationship Name of referee Occupation / relationship to you Address of referee Daytime telephone number Email address
Vetting of Student / Work Placements (Garda / Access NI Vetting) Because of the nature of our work with vulnerable young people and adults, we need to know the following Garda Vetting / Access NI Clearance Yes No provided by college? Do you have a criminal record? *
Yes
No
* NB. This includes ‘spent’ convictions. If the answer is yes, we may need to discuss it with you. It will not necessarily prevent you from becoming a Student placement. If you wish, you may give further details below.
Declaration I declare that the information given on this form is complete and correct to the best of my knowledge and that I understand that inaccurate or false information given may result in an offer of placement being withdrawn. Applicants Signature Date
Forms must be signed and dated. Completed Application Forms should be returned to: Volunteer Coordinator, Depaul Ireland, Sundial House, 140 James’s Street, Dublin 8, Ireland. You may also fax your form to (+353 1) 607 4476. Please note we do not accept emailed forms.