Ymca Housing Application Form For Supported Housing (Page 8 of 8) in pdf

DATA PROTECTION ACT

It is necessary for YMCA Housing to carry out background checks of all applicants. It

may also be necessary to undertake further checks should a licence be granted and

there are some concerns about your placement. Your permission is requested to carry

out these checks. If you agree to these checks being carried out, please sign below.

You should be aware that, under the Data Protection Act, information from these

agencies can only be obtained with your consent. A copy of this sheet will be sent to the

other agencies that we approach for background information. If there are good reasons

why we may not contact an individual or agency, please state this below.

I hereby authorise Fylde Coast YMCA to make the necessary enquiries regarding my

placement. I consent to a police check being carried out on me.

I am aware that these enquiries may involve Fylde Coast YMCA employees contacting

any of the following agencies or individuals listed below (apart from any listed as

exceptions) and/or other people or agencies referred to in my application form (as

appropriate):

Parents or Family Members

Benefits Agencies

Police

Previous or Current Landlords

Banks / Building Societies

Past or Current Employers

Medical Professionals

Referral Agency

Social Services

Probation Services or Youth Offending Service

Young Peoples Services

Local Authorities

Immigration

Agencies or Individuals who must not be contacted: .

……………………………….….………….…..…….

…………………………………….……………………………………………………………………..………………………………..

Applicant’s Name: .

……………………………………………………………………………………………………………...

Other Names Applicant has been Known by:

………………………………..….……………………..…………

Current Address (or Previous Address if no Current Address):

…………………………………….……………………………………………………………………..………………………………..

Place of Birth:

Date of Birth:

……………………………………

….….…..……..……..…......

National Insurance Number:

…..……..…..…..…..…..……………………….

Signed: ..

Date Signed:

…..…..…..…..…..…...…..…..…..…..…..…..………..…..………

….………………………..

Application/first interview - Application Form V3.1

Updated October 2010

Ymca Housing Application Form For Supported Housing Page 8

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