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CHURCH OF ENGLAND - DIOCESE OF SOUTHWARK Subject Leader for P !

"#ca$ Educat#o% A&&$#cat#o% SOUTHWARK DIOCESAN BOARD of EDUCATION

CONFIDENTIAL NA'E OF SCHOOL( C r#"t)" Sc oo$* +uee%)" Road* R#c ,o%d* Surre!* TW-. /HU

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

(lease state % ere you sa% t e ad)ertisement for t is post:

- APPLICANT0S PERSONAL DETAILS T*T+,: -*R.T /AM,: .0R/AM,:

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1 TEACHER STATUS

*f you are registered %it t e 8eneral Teac ing Council as a &ualified teac er in t is country, please gi)e date of recognition: Are t ere any restrictions on your residence or employment in t e 059 *f 7es, please gi)e details 2 SUPPORTING STATE'ENT 7es /o

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4it reference to t e 8o)ernors< selection criteria please gi)e details of your e=perience, s$ills, a'ilities and additional information % ic you t in$ %ould 'e useful in t is >o'# (lease %rite t is on a separate s eet?s@ of paper#

3 PRESENT OR 'OST RECENT E'PLO4'ENT

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5 PRE6IOUS TEACHING E'PLO4'ENT 7"tart 8#t ,o"t rece%t 9 &$ea"e e:&$a#% a%! ;a&" #% e,&$o!,e%t< .c ool, college or ot er employer Type A status of esta'lis ment Age range and roll ?appro=@ Title of post ?include special responsi'ilities@ 3ates of employment

/ EDUCATION AND ACADE'IC +UALIFICATIONS .c ool:college:uni)ersity -rom To .u'>ects:Bualifications:8rades:!onours, dates a%arded and a%arding 'ody

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.econdary ?post 1C@

!ig er ,ducation

-urt er postgraduate &ualifications ?including (8C,@

= IN-SER6ICE TRAINING UNDERTAKEN DURING THE PAST 2 4EARS RELE6ANT TO THIS APPLICATION Course title (ro)ider 3ates A duration of course A%ard ?if any@

> OTHER PAID WORK E?PERIENCE 7&$ea"e e:&$a#% a%! ;a&" #% e,&$o!,e%t< ,mployer -rom To /ature of 2ccupation

@ DETAILS OF OTHER ACTI6ITIES* SKILLS AND INTERESTS RELE6ANT TO THIS POST

-. RELIGIOUS AFFILIATION

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Are you an Anglican communicant9

Are you a regular %ors ipper %it in t e Anglican C urc 9

8i)e details of mem'ers ip of any ot er C ristian denomination:

3etails of your &ualifications and e=perience % ic you feel are especially rele)ant to teac ing in a C urc of ,ngland sc ool:

-- PROFESSIONAL REFERENCES - &$ea"e "u&&$! t e %a,e" a%d addre""e" of t8o &er"o%" 8#$$#%; to &roA#de refere%ce"B O%e refere%ce " ou$d be fro, !our &re"e%t eadteac er a%d t e ot er " ou$d co,e fro, !our LEAB /AM,: A33R,..: (2.*T*2/ !,+3: (lease state t e conte=t in % ic t is person is $no%n to yourself:

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(2.*T*2/ !,+3: (lease state t e conte=t in % ic t is person is $no%n to yourself:

-1 DECLARATION C4 APPLICANT * understand t at appointment to t is post is su'>ect to a satisfactory ,n anced Criminal Records 6ureau disclosure# * also understand t at, under t e terms of t e Re a'ilitation of 2ffenders Act 19E4 ?,=ceptions 2rder 19E;, and su'se&uent amendments@, * am re&uired to disclose any record * may a)e of criminal con)ictions, cautions and 'indFo)ers, including t ose regarded as GspentH and to attac details of t e same#I !a)e you a record of criminal con)ictions, cautions or 'indFo)ers9 7es ?details attac ed@ /o

I (lease note information a'out criminal con)ictions, cautions and 'indFo)ers %ill remain confidential 'ut %ill 'e made a)aila'le to t e panel for consideration if your application is ot er%ise deemed %ort y of s ortFlisting#

* declare t at * am not on +ist 99, or dis&ualified from %or$ing %it c ildren, or su'>ect to any sanctions imposed 'y a regulatory 'ody ?i#e# t e 8eneral Teac ing Council@

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* understand t at under t e terms of t e Asylum and *mmigration Act 199C s ould * 'e s ortFlisted for t e post for % ic * am applying, * %ill pro)ide for t e go)erning 'ody, as employer, an original documentI s o%ing my entitlement to %or$ in t is country#
IAccepta'le documents include your /ational *nsurance card, a 'irt certificate issued in t e 05 or ,ire, a (4; from your pre)ious employer, a )alid passport, or any rele)ant aut orisation allo%ing you to %or$ in t is country#

* appreciate t at * must declare any family or close relations ip %it a mem'er of t e sc ool<s 8o)erning 6ody, an employee of t e sc ool or senior official of t e local education aut ority % 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 $no%ledge and 'elief, t at all &uestions a)e 'een fully and accurately ans%ered, and t at * possess all &ualifications % ic * claim to old# * understand t at my name %ill 'e %it dra%n from t e list of candidates if, prior to appointment, * am found $no%ingly to a)e omitted or concealed any rele)ant fact a'out my eligi'ility for t e post, and * ac$no%ledge t at suc disco)ery su'se&uent to appointment is li$ely to lead to my dismissal %it out notice# * ere'y consent to t e processing of sensiti)e personal data, as defined 'y t e 3ata (rotection Act 199J, in)ol)ed in t e consideration of t is application# .*8/,3: 3AT,:

ADDITIONAL INFOR'ATION 7CONFIDENTIAL< - T #" "ect#o% of t e for, "eeD" add#t#o%a$ #%for,at#o% &ert#%e%t to !our a&&$#cat#o%B It 8#$$ be re,oAed before " ort$#"t#%; a%d 8#$$ %ot be "ee% b! a%! ,e,ber" of t e "e$ect#o% &a%e$B Acce"" to #t 8#$$ be $#,#ted to "taff #%Ao$Aed #% ad,#%#"ter#%; t e a&&o#%t,e%t &roce"" 8 o %eed acce"" for eEua$ o&&ortu%#t#e" ,o%#tor#%; or to taDe ad,#%#"trat#Ae act#o% ba"ed u&o% t e #%for,at#o% &roA#ded eB;B Occu&at#o%a$ Hea$t referra$ Po"#t#o% a&&$#ed for( Title: 3ate of 'irt : HEALTH (lease state, %it dates, any serious illnesses or operations you a)e ad: 3o you suffer from recurring ailments9 *f 7es, 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 t%el)e mont s9 *f 7es, please gi)e details 'elo%: 3o you consider t at you a)e any disa'ility as defined %it in t e terms of t e 3isa'ility 3iscrimination Act 199;, % ic as a su'stantial effect on your a'ility to carry out normal day to day acti)ities9 7es /o *f 7es, please gi)e 'rief details of t e disa'ility and any ad>ustments % ic you consider you %ould need to 'e made to ena'le you to carry out t e post for % ic you are applying: 4ill you re&uire assistance if called for an inter)ie%9 *f 7es, please gi)e details: 7es /o 7es /o -irst name: .urname

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E+UAL OPPORTUNITIES 'ONITORING - 8e 8#" to ,o%#tor co%t#%uou"$! 7#% t e "tr#cte"t co%f#de%ce< t e &ro;re"" of our EEua$ O&&ortu%#t#e" Po$#c!B P$ea"e e$& u" b! ;#A#%; t e fu$$e"t &o""#b$e a%"8er" to t e Eue"t#o%" be$o8B Se:( M A;e( 20F29 D0FD9I 40F49 ;0F;9 C0FC;

P$ea"e #%d#cate !our cu$tura$Fet %#c or#;#%" T is information is included as part of t e duty of t e sc ool to promote race e&uality and to ensure e&ual opportunities for all staff and is recommended 'y t e Commission for Racial ,&uality ?%%%#cre#go)#u$@# White 6ritis ,nglis .cottis 4els 2t er: please %rite in *ris Any ot er 4 ite 'ac$ground: please %rite in Black, Black British, Black English, Black Scottish or Black Welsh Cari''ean African Any ot er 6lac$ 'ac$ground: please %rite in Asian, Asian British, Asian English, Asian Scottish or Asian *ndian (a$istani 6anglades i Any ot er Asian 'ac$ground: please %rite in Mixed 4 ite A 6lac$ Cari''ean 4 ite A 6lac$ African 4 ite A Asian Any ot er Mi=ed 'ac$ground: please %rite in Chinese, Chinese British, Chinese English, Chinese Scottish or Chinese Welsh or other ethnic group C inese Any ot er 'ac$ground: please %rite in Prefer not to state Put a cross here if you prefer not to state your ethnic group

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Note" to a&&$#ca%t" 6efore signing t is form please c ec$ 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 %is us to ac$no%ledge your application# 7ou are reminded t at t is is an application form for a post in a C urc of ,ngland:C urc in 4ales 1oluntary Aided sc ool or a -oundation sc ool in % ic t e 8o)erning 6ody is t e employer# *f you are appointed t e Contract you %ill 'e as$ed to sign %ill include t e follo%ing 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 4ales 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$e not to do anyt ing in any %ay contrary to t e interests of t e -oundation# 7ou are re&uired to gi)e and:or super)ise t e gi)ing of religious education in accordance %it t e doctrines of t e C urc of ,ngland:C urc in 4ales and Trust 3eed of t e .c ool# 7ou are re&uired to ta$e part in and lead acts of religious %ors ip#

T e successful applicant %ill 'e re&uired to pro)ide an ,n anced 3isclosure from t e CR6#

Details of referees 2ne referee s ould 'e your current or most recent employer# *f you are not currently %or$ing %it c ildren 'ut a)e done so in t e past, a reference %ill 'e re&uired from t e employer 'y % om you %ere most recently employed in %or$ %it c ildren# T e sc ool %ill see$ references on s ortFlisted candidates, and may approac pre)ious employers for information to )erify particular e=perience of &ualifications, 'efore t e inter)ie%# *f you are currently %or$ing %it c ildren, on a paid or )oluntary 'asis, your current employer %ill 'e as$ed a'out disciplinary offences relating to c ildren, including any penalty % ic is time e=pired and % 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 %or$ing %it c ildren 'ut a)e done so in t e past, t e rele)ant pre)ious employer %ill 'e as$ed a'out t ose issues# References from relati)es or friends %riting solely in t e capacity of friends %ill not 'e accepted#

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