Lay Member Application Form for Board or Sub Groups
Please indicate which you are interested in applying for with an X
Luton Safeguarding Adults Board
Luton Safeguarding Children’s Board
Would you also consider joining a Sub
Group rather than the Board?
1. Personal details:
Surname:
First Names:
Home Address
(including post
code):
Contact Telephone
Numbers:
Email Address:
2. Residency question:
(Delete as appropriate)
Do you currently reside within the Luton Borough Council border
and expect to remain so within the next 12 months at least?
Yes /
No
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3. Other Questions:
(Delete as appropriate)
Do you have any prior connections with agencies working with
Yes /
children in this County?
Do you have any prior connection with elected members in this
Yes /
County?
Have you been a Councillor or Officer of Luton Borough Council
Yes /
or any other local authority/statutory agency in the last five
years?
Are you a relative or close friend of a Councillor or Officer of
Yes /
Luton Borough Council?
Are you an active member of a political party?
Yes /
If you have answered yes to any of the above questions please give details:
No
No
No
No
No
4. Current and Previous Employment and Voluntary Positions:
Name and Address
of Employer:
Job title:
Outline of
responsibilities:
Date appointed:
Date left position:
Reason for seeking
other employment:
2
Name and Address
of Employer:
Job title:
Outline of
responsibilities:
Date appointed:
Date left position:
Reason for seeking
other employment:
Name and Address
of Employer:
Job title:
Outline of
responsibilities:
Date appointed:
Date left position:
Reason for seeking
other employment:
Please continue on separate sheet/s if necessary.
3
5. Education:
Name of
School/College/University
Qualification achieved
Grade
Date awarded
6. Training:
Please include details of professional or personal development relevant to the role.
Continue on separate sheet/s if necessary.
Name of course
Organising Body
Brief Description
Date
4
7. Personal Statement:
The text box below will expand if being completed electronically but please continue
on separate sheet/s if necessary.
In no more than 1,000 words please let us know why you wish to be
considered for this role.
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8. References
Your current or most recent employer must be one of your references.
Reference 1
Full name
Title/Position
Name of
organisation
Address (incl
postcode)
Telephone
Number
Email
Address
Relationship
to Applicant
Reference 2
Full name
Title/Position
Name of
organisation
Address (incl
postcode)
Telephone
Number
Email
Address
Relationship
to Applicant
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9. Disclosure of criminal convictions and Rehabilitation of Offenders Act 1974
The role which you are applying for is exempt from the Rehabilitation of Offenders
Act 1974 and all subsequent amendments (England and Wales). For these positions
you are not entitled to withhold information about police cautions, bind overs, or any
criminal convictions including any that would otherwise be considered ‘spent’ under
the Act.
Have you ever been convicted of any offence or bound-over or given a
caution?
Yes /
No
If yes, please give details on a separate sheet and attach it to this form in a
sealed envelope marked ‘Confidential Disclosure’, or in a separate password
protected document (if sending by email).
I confirm that the information given on this form is correct. I understand that
misleading statements may be sufficient grounds for cancelling any
subsequent appointment made. Submission of this form indicates your explicit
consent that your data may be processed in accordance with the provision of
the Date Protection Act 1998.
Signed:
Date:
Please return this form and the Equal Opportunity Monitoring Form by post or
preferably email, to: [email protected]
or
Luton Safeguarding Children’s Board
1st Floor, Town Hall Extension
Luton Borough Council LU1 2BQ
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