School Governor Application Form Please return by email to gary.phillips@lilianbaylis.com with CV attached The post you are applying for is EXEMPT from the Rehabilitation of Offenders Act (1974). This means that you are required to give details of any spent and unspent convictions or pending cases, cautions, bind-over orders, reprimands and final warnings, including dates, the offence(s), sentences, and the court or police force which dealt with the offence. These should be detailed in section 6 Lambeth Council and Lilian Baylis Technology School are committed to safeguarding and promoting the welfare of children and young people and expects all staff and volunteers to share this commitment. 1.0 Personal details Title: First Names: Surname: Address and Postcode: Contact address (if different): E mail address: Daytime telephone: Mobile telephone: 2.0 Please attach a curriculum vitae that details your education and employment history 3.0 Other information How did you find out about governor vacancies? Have you ever been or are you currently a governor? Yes No If yes please give details of the school, type of governor and period of office: 1
4.0 Referees Name Capacity known Address Professional Referee Personal Referee Email Phone 5.1 Why are you interested in becoming a Governor of Lilian Baylis Technology School? 150 words 5,2 What specific knowledge, skills and understanding do you feel you can contribute? 150 words 2
6.0 Disqualification Criteria and Vetting A person wishing to be a school governor must be able to make the following declaration: I am aged 18 or over at the date of this election or appointment; I do not already hold a governorship of the same school; I am not the subject of a bankruptcy restrictions order or an interim order, debt relief restrictions order, an interim debt relief restrictions order and my estate has not been sequestrated and the sequestration has not been discharged, annulled or reduced; I am not subject to a disqualification order or disqualification undertaking under the Company Directors Disqualification Act 1986, a disqualification order under Part 2 of the Companies (Northern Ireland) Order 1989, a disqualification undertaking accepted under the Company Directors Disqualification (Northern Ireland) Order 2002, or an order under section 429(2) (b) of the Insolvency Act 1986 (failure to pay under county court administration order); I have not been removed from the office of charity trustee or trustee for a charity by the Charity Commission or Commissioners or High Court on grounds of any misconduct or mismanagement, or under section 34 of the Charities and Trustee Investment (Scotland) Act 2005 from being concerned in the management or control of any body; I have not been included in the list of teachers or workers considered by the Secretary of State as unsuitable to work with children or young people; I have not been barred from any regulated activity relating to children; I have not been disqualified from working with children or from registering for childminding or providing day care; I have not been disqualified from being an independent school proprietor, teacher or employee by the Secretary of State; I have not been sentenced to three months or more in prison (without the option of a fine) in the five years before becoming a governor or since becoming a governor; I have not received a prison sentence of two years or more in the 20 years before becoming a governor; I have not at any time received a prison sentence of five years or more; I have not been fined for causing a nuisance or disturbance on school premises during the five years prior to or since appointment or election as a governor; I have not and will not refuse a request by the Clerk to make an application to the Disclosure & Barring Service for a criminal records certificate. Declaration A. I have read the summary of regulations above and confirm that I am not disqualified from serving as a school governor and that in the event that I am appointed to a governing body, I will notify the clerk to the governing body immediately should I become disqualified during my term of office. I understand it is an offence to serve as a school governor if disqualified. B. The information given is correct and complete to the best of my knowledge and belief. C. You are required to give details of all current (unspent) and spent convictions or pending cases, cautions, bind-over orders, reprimands and final warnings, including dates, the offence(s), sentences, and the court or police force which dealt with the offence. Details of all current (unspent) and spent convictions or pending cases, cautions, bind-over orders, reprimands and final warnings, including dates, the offence(s), sentences, and the court or police force which dealt with the offence. None As detailed below 3
Signed: Monitoring information Date: This form is separated from the main application form and will not be provided to the short-listing panel. Your answers will be treated in the strictest confidence and the information you provide will only be used for monitoring purposes. How you complete this form has no connection to the evaluation of your application in any way. Surname: Forenames: Date of Birth: Sex: Male Transgender Female Position Title ABOUT YOU. (a) White (b) Mixed (c) Asian or Asian British (d) Black or Black British (e) Chinese or Other School Governor What is your ethnic group? Please choose one selection from (a) to (e) and then tick the appropriate box to indicate your cultural background. British Irish White and black Caribbean White and black African White and Asian Indian Pakistani Bangladeshi Caribbean African Chinese ABOUT YOU Do you consider yourself disabled under the 1995 Disability Discrimination Act? Yes No ABOUT YOU How would you describe your sexuality? Optional. Please tick one box only. Heterosexual Gay Bisexual Lesbian ABOUT YOU What is your faith / religion / belief? Optional. Please tick one box only. Agnostic Humanist Atheist Jewish Buddhist Muslim Christian Sikh Hindu Other. Please specify 4
How did you find out about this vacancy? (Please give the name of the newspaper/ journal/website). 5