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Room Hire Application Form

Change Room Hire Application Form
Please can you print this form and send by post.

Date………………………… Room Usage…………………………………………………….

Title: Mr/Mrs/Miss/Other: ………………..Date of Birth: ……………………………….

Surname:…………………………………… Forenames:…………………………………….

Address :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Contact Telephone Numbers: Home:
Work:
Mobile:

Email Address:

Qualifications
School/University/ Training Body Start
Date Finish
Date Qualifications Date of qualification

DBS Number and date of issue
Indemnity Insurance number and broker
Professional body name and membership number

Please briefly state what the purpose is for renting the therapy rooms and the days, times and frequency you require.

Referrees ( for individual Usage only)

Please give the name’s address’s and email address’s of TWO Referees.
Reference 1:

Reference 2:

Rehabilitation of Offenders Act 1974
An enhanced criminal record bureau check will be required before room hire is agreed. This will include details of cautions, reprimands, final warnings and convictions including spent convictions under the terms of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 2001. If your practice involves working with vulnerable groups a disclosure will be required.
Data Protection Act 1998
I understand that CHANGE may store information I have given on this form, and that I have the right to see a copy of the information held about myself on application to the committee.
Declaration
I certify that, to the best of my knowledge, the information I have given is correct. Providing false information or deliberately omitting relevant information will lead to cancellation of room rental agreement.

Signed:……………………………………………………….. Date………………………………..

Please return the completed form to:
Change Birmingham Brief Therapy
The Big Peg
120 Vyse Street
Hockley
Birmingham
B18 6NF
0121 638 0670

Email: changebt@solution.fsnet.co.uk

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