Templesprings C3 Youth Programme Application Form

C3 Youth Programme Application Form
C3 is a Templesprings youth programme for 11–19-year-olds and stands for our three key core values of Commitment, Communication and Consistency. We provide Barclays Life Skills training, Arts Award, Work Placements for Schools and Colleges and other volunteering opportunities for young people.

Our aim is to create an environment where young people can:
- explore possibilities in the area of their skills, talents, creativity and aspirations
- express their gifts and talents through performances, volunteering, peer mentoring and work placement
- expand and develop new skills and their vision of what is possible
Thank you for your interest in our C3 Youth Programme. We would love for you to join us on this exciting journey!! Simply fill out this form to apply. Spaces are limited so don’t miss out on this amazing opportunity!!

PS: Parents should please complete form on behalf of the young persons if they are minors (ages 11-17)
Personal Information - Young Person
Name*

First NameLast Name
Gender*

MaleFemale
Mobile Telephone*
Email Address*
example@example.com
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Education/ Employment Status
Please tick which applies*

Full-time StudentPart-time StudentWorking Part-timeWorking Full-timeSelf-employedUnemployed
Name of Current School/College /Employer*
Courses/Job Title*
E.g. GCSE, A-Levels etc.
Ethnic Origin
Please Select your Ethnicity*
References

Please provide the names of two people who have known you for at least 12 months. We will accept one professional and one personal reference. Also, depending on the role you will be required to undergo a DBS Check.
Professional Reference Full name*

First NameLast Name
Relationship*
E.g Teacher
Email*
example@example.com
Reference 2 - Personal
Personal Reference Full name*

First NameLast Name
Relationship*
e.g Parent, Friend
Email*
example@example.com
Volunteering
Why do you want to join the C3 Youth Programme?*
What experience do you have of voluntary work?*
What experience do you have in working with or participating in any youth-based programmes?*
What personal qualities do you feel you can bring to the C3 Youth Programme?*
E.g. I am good at writing
Psychological Wellbeing and General Health

Important Note: The questions on the next page are about your health, both physical and psychological. Please answer the questions honestly. There are no correct answers and no set issues that immediately disqualify you from participating. As we work with children and as part of our safeguarding policy, the information we request is important to maintain a safe environment. If there are any issues that are of concern to us, we shall discuss them with you and help signpost you if . The information is held in confidence and will only be accessible to those people who need to know.
Psychological Well-being
1. Have you ever been treated for depression?*
If yes, when was this and what treatment did you receive?
2. Have you ever attempted suicide?*
If yes, when was this and how did you attempt suicide?
3. Have you ever experienced violence?*
If yes, when and from whom?
4. Have you ever been violent?*
If yes, when and towards whom?
5. Have you ever suffered with any other mental health/ psychological problem?*
If yes, what was this, when was this and what treatment did you receive?
6. Have you ever been to see a psychologist, counselor, therapist or psychiatrist?*
If yes, when was this, how long were you receiving treatment and why?
7. Have you ever been admitted onto a psychiatric ward?*
If yes, when was this; how long were you an in-patient? Why were you admitted and which unit were you admitted to?
8. Are you currently in any form of therapy, counselling, psychological or psychiatric treatment?*
If yes, 1) why are you receiving treatment; 2) since when have you been receiving treatment; 3) who is treating you and 4) what is their contact details?
General Health
1. Do you smoke?*
If yes, how many per day?
2. Describe your alcohol consumption?*

NeverOccasional (several times a month)Sometimes (2-3 times weekly)Often (more than 3 times a week)
3. Do you use any drugs other than prescribed medications?*
If yes, what drugs and how often
4. How often do you exercise?*

NeverOccasional (several times a month)Sometimes (2-3 times weekly)Often (more than 3 times a week)
Signatures
Parent's Signature*

Clear
Templesprings Registered Charity Number 1125084

C3 Youth Mentoring Application Form
Should be Empty:

C3 Youth Programme Application Form

Personal Information - Young Person

Education/ Employment Status

Ethnic Origin

References

Volunteering

Psychological Wellbeing and General Health

Signatures