Name *

First Name

Last Name

Have you ever been involved with the Police such as interviewed, questioned, subject to a court order, bound-over, received a reprimand, warning, cautioned or convicted? *

Yes

No

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amended) 2013? *

Yes

No

Have you ever been known to any children’s services department or to the police as being a risk or potential risk to children? *

Yes

No

Have you been the subject of any disciplinary investigation and/or sanction by any organisation due to concerns about your behaviour towards children? *

Yes

No

Do you have parental responsibility for a child who is being assessed or who has been placed on a Child Protection Plan under Section 47 of the Children’s Act 1989? *

Yes

No

Is there anything else that you would like to tell us that may affect your suitability to work with children? *

Yes

No

I agree that the information provided here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or disciplinary action may be taken if information is not disclosed by me and subsequently come to the organisation’s attention. *

Yes

If I am offered a position, I agree to register with the DBS update service, and I give permission for you to check my online certificate. *

Yes

In accordance with the organisation’s procedures if required I agree to provide a valid DBS certificate and consent to the organisation clarifying any information provided on the disclosure with the agencies providing it. *

Yes

I agree to inform the organisation within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children or young people. *

Yes

I understand that the information contained on this form, the results of the DBS check and information supplied by third parties may be supplied by the organisation to other persons or organisation’s in circumstances where this is considered necessary to safeguard children. *

Yes