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CHURCH OF ENGLAND - DIOCESE OF SOUTHWARK ASSISTANT HEADTEACHER APPLICATION SOUTHWARK DIOCESAN BOARD of EDUCATION

CONFIDENTIAL NAME OF SCHOOL: Christs Schoo ! "#$$%s Ro&'! Rich(o%'! S#rr$)! TW*+ ,HU

Closing date for completed form: 9am, Tuesday, 22nd April 2014 Return form to: Mrs Amanda Mylles to w om all !ueries s ould "e addressed: #R$c rists%ric mond%sc %u&

'lease state w ere you saw t e ad(ertisement for t is post:

* APPLICANT-S PERSONAL DETAILS T)T*+: ,)R-T .AM+: -/R.AM+:

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. TEACHER STATUS

Are t ere any restrictions on your residence or employment in t e /47 )f 6es, please gi(e details / SUPPORTING STATEMENT

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3it reference to t e 8o(ernors9 selection criteria please gi(e details of your e:perience, s&ills, a"ilities and additional information w ic you t in& would "e useful in t is ;o"% 'lease write t is on a separate s eet<s= of paper%

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0 PRESENT OR MOST RECENT EMPLO1MENT

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2 PRE3IOUS TEACHING EMPLO1MENT 4st&rt 5ith (ost r$c$%t 6 $&s$ $76 &i% &%) 8&6s i% $(6 o)($%t9 -c ool, college or ot er employer Type @ status of esta"lis ment Age range and roll <appro:= Title of post <include special responsi"ilities= 2ates of employment

, EDUCATION AND ACADEMIC "UALIFICATIONS -c ool>college>uni(ersity -econdary <post 1B= ,rom To -u";ects>Aualifications>8rades>#onours, dates awarded and awarding "ody

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#ig er +ducation

,urt er postgraduate !ualifications <including '8C+=

: IN-SER3ICE TRAINING UNDERTAKEN DURING THE PAST / 1EARS RELE3ANT TO THIS APPLICATION Course title 'ro(ider 2ates @ duration of course Award <if any=

; OTHER PAID WORK E<PERIENCE 46 $&s$ $76 &i% &%) 8&6s i% $(6 o)($%t9 +mployer ,rom To .ature of 1ccupation

= DETAILS OF OTHER ACTI3ITIES! SKILLS AND INTERESTS RELE3ANT TO THIS POST

*+ RELIGIOUS AFFILIATION Are you an Anglican communicant7

Are you a regular wors ipper wit in t e Anglican C urc 7

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8i(e details of mem"ers ip of any ot er C ristian denomination:

2etails of your !ualifications and e:perience w ic you feel are especially rele(ant to teac ing in a C urc of +ngland sc ool:

** PROFESSIONAL REFERENCES - 6 $&s$ s#66 ) th$ %&($s &%' &''r$ss$s o> t5o 6$rso%s 5i i%8 to 6ro?i'$ r$>$r$%c$s@ O%$ r$>$r$%c$ sho# ' A$ >ro( )o#r 6r$s$%t h$&'t$&ch$r &%' th$ oth$r sho# ' co($ >ro( )o#r LEA@ .AM+: A22R+--: '1-)T)1. #+*2: 'lease state t e conte:t in w ic t is person is &nown to yourself:

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'1-)T)1. #+*2: 'lease state t e conte:t in w ic t is person is &nown to yourself:

*. DECLARATION B1 APPLICANT ) understand t at appointment to t is post is su";ect to a satisfactory +n anced Criminal Records 5ureau disclosure% ) also understand t at, under t e terms of t e Re a"ilitation of 1ffenders Act 19D4 <+:ceptions 1rder 19D?, and su"se!uent amendments=, ) am re!uired to disclose any record ) may a(e of criminal con(ictions, cautions and "indEo(ers, including t ose regarded as FspentG and to attac details of t e same%H #a(e you a record of criminal con(ictions, cautions or "indEo(ers7 6es <details attac ed= .o

H 'lease note information a"out criminal con(ictions, cautions and "indEo(ers will remain confidential "ut will "e made a(aila"le to t e panel for consideration if your application is ot erwise deemed wort y of s ortElisting%

) declare t at ) am not on *ist 99, or dis!ualified from wor&ing wit c ildren, or su";ect to any sanctions imposed "y a regulatory "ody <i%e% t e 8eneral Teac ing Council= ) understand t at under t e terms of t e Asylum and )mmigration Act 199B s ould ) "e s ortElisted for t e post for w ic ) am applying, ) will pro(ide for t e go(erning "ody, as employer, an original documentH s owing my entitlement to wor& in t is country%
HAccepta"le documents include your .ational )nsurance card, a "irt certificate issued in t e /4 or +ire, a '4? from your pre(ious employer, a (alid passport, or any rele(ant aut orisation allowing you to wor& in t is country%

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) appreciate t at ) must declare any family or close relations ip wit a mem"er of t e sc ool9s 8o(erning 5ody, an employee of t e sc ool or senior official of t e local education aut ority w ic as responsi"ility for t e sc ool% ) understand t at failure to disclose suc a relations ip may result in my dis!ualification% ) certify t at all information gi(en "y me on eac section of t is form and in supporting documents is correct to t e "est of my &nowledge and "elief, t at all !uestions a(e "een fully and accurately answered, and t at ) possess all !ualifications w ic ) claim to old% ) understand t at my name will "e wit drawn from t e list of candidates if, prior to appointment, ) am found &nowingly to a(e omitted or concealed any rele(ant fact a"out my eligi"ility for t e post, and ) ac&nowledge t at suc disco(ery su"se!uent to appointment is li&ely to lead to my dismissal wit out notice% ) ere"y consent to t e processing of sensiti(e personal data, as defined "y t e 2ata 'rotection Act 199I, in(ol(ed in t e consideration of t is application% -)8.+2: 2AT+:

ADDITIONAL INFORMATION 4CONFIDENTIAL9 - This s$ctio% o> th$ >or( s$$Cs &''itio%& i%>or(&tio% 6$rti%$%t to )o#r &66 ic&tio%@ It 5i A$ r$(o?$' A$>or$ short isti%8 &%' 5i %ot A$ s$$% A) &%) ($(A$rs o> th$ s$ $ctio% 6&%$ @ Acc$ss to it 5i A$ i(it$' to st&>> i%?o ?$' i% &'(i%ist$ri%8 th$ &66oi%t($%t 6roc$ss 5ho %$$' &cc$ss >or $D#& o66ort#%iti$s (o%itori%8 or to t&C$ &'(i%istr&ti?$ &ctio% A&s$' #6o% th$ i%>or(&tio% 6ro?i'$' $@8@ Occ#6&tio%& H$& th r$>$rr& Positio% &66 i$' >or: Title: 2ate of "irt : HEALTH 'lease state, wit dates, any serious illnesses or operations you a(e ad: 2o you suffer from recurring ailments7 )f 6es, please specify #a(e you "een a"sent from your employment t roug illness for more t an ? days in total in t e last twel(e mont s7 )f 6es, please gi(e details "elow: 2o you consider t at you a(e any disa"ility as defined wit in t e terms of t e 2isa"ility 2iscrimination Act 199?, w ic as a su"stantial effect on your a"ility to carry out normal day to day acti(ities7 6es .o )f 6es, please gi(e "rief details of t e disa"ility and any ad;ustments w ic you consider you would need to "e made to ena"le you to carry out t e post for w ic you are applying: 3ill you re!uire assistance if called for an inter(iew7 )f 6es, please gi(e details: 6es .o 6es .o ,irst name: -urname

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E"UAL OPPORTUNITIES MONITORING - 5$ 5ish to (o%itor co%ti%#o#s ) 4i% th$ strict$st co%>i'$%c$9 th$ 6ro8r$ss o> o#r ED#& O66ort#%iti$s Po ic)@ P $&s$ h$ 6 #s A) 8i?i%8 th$ ># $st 6ossiA $ &%s5$rs to th$ D#$stio%s A$ o5@ S$7: M , A8$: 20E29 C0EC9H 40E49 ?0E?9 B0EB?

P $&s$ i%'ic&t$ )o#r c# t#r& E$th%ic ori8i%s T is information is included as part of t e duty of t e sc ool to promote race e!uality and to ensure e!ual opportunities for all staff and is recommended "y t e Commission for Racial +!uality <www%cre%go(%u&=% White 5ritis +nglis -cottis 3els 1t er: please write in )ris Any ot er 3 ite "ac&ground: please write in Black, Black British, Black English, Black Scottish or Black Welsh Cari""ean African Any ot er 5lac& "ac&ground: please write in Asian, Asian British, Asian English, Asian Scottish or Asian )ndian 'a&istani 5anglades i Any ot er Asian "ac&ground: please write in Mixed 3 ite @ 5lac& Cari""ean 3 ite @ 5lac& African 3 ite @ Asian Any ot er Mi:ed "ac&ground: please write in Chinese, Chinese British, Chinese English, Chinese Scottish or Chinese Welsh or other ethnic group C inese Any ot er "ac&ground: please write in Prefer not to state Put a cross here if you prefer not to state your ethnic group

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Not$s to &66 ic&%ts 5efore signing t is form please c ec& t at e(ery section as "een completed% T e form s ould "e returned as instructed in t e details of t e post% +nclose a stamped addressed en(elope if you wis us to ac&nowledge your application% 6ou are reminded t at t is is an application form for a post in a C urc of +ngland>C urc in 3ales 0oluntary Aided sc ool or a ,oundation sc ool in w ic t e 8o(erning 5ody is t e employer% )f you are appointed t e Contract you will "e as&ed to sign will include t e following clause <t e second paragrap is omitted in t e case of a ,oundation sc ool=: o As an Assistant #eadteac er of a C urc of +ngland>C urc in 3ales sc ool you are re!uired to a(e regard to t e C ristian c aracter of t e sc ool and its ,oundation and to underta&e not to do anyt ing in any way contrary to t e interests of t e ,oundation% 6ou are re!uired to gi(e and>or super(ise t e gi(ing of religious education in accordance wit t e doctrines of t e C urc of +ngland>C urc in 3ales and Trust 2eed of t e -c ool% 6ou are re!uired to ta&e part in and lead acts of religious wors ip%

T e successful applicant will "e re!uired to pro(ide an +n anced 2isclosure from t e CR5%

Details of referees 1ne referee s ould "e your current or most recent employer% )f you are not currently wor&ing wit c ildren "ut a(e done so in t e past, a reference will "e re!uired from t e employer "y w om you were most recently employed in wor& wit c ildren% T e sc ool will see& references on s ortElisted candidates, and may approac pre(ious employers for information to (erify particular e:perience of !ualifications, "efore t e inter(iew% )f you are currently wor&ing wit c ildren, on a paid or (oluntary "asis, your current employer will "e as&ed a"out disciplinary offences relating to c ildren, including any penalty w ic is time e:pired and w et er you a(e "een t e su";ect of any c ild protection concerns, and if so, t e outcome of t e en!uiry or disciplinary procedure% )f you are not currently wor&ing wit c ildren "ut a(e done so in t e past, t e rele(ant pre(ious employer will "e as&ed a"out t ose issues% References from relati(es or friends writing solely in t e capacity of friends will not "e accepted%

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