St Fagans CC est 1862

Coaches self-declaration form

St Fagans CC Coaches Self-Declaration Form

Please complete (or request a hard copy from Tony Davies – tony194758@googlemail.com)

Name

Any surname previously
known by
Address
Date of Birth
Place of Birth

Personal declaration form for all staff working or in regulated positions (contact with children, young people, and vulnerable adults and people with access to personal data)

Confidential

Have you ever been convicted of a criminal offence or been the subject of a caution or bound over order? (Please include all offences, however minor, and spent convictions.

YES NO

If YES, please state the nature and dates of the offence(s):

 

Have you ever been subject to any disciplinary action or sanctions relation to child abuse?

YES NO

If YES, please state the nature and dates of the offence(s):

 

You are required to self-certify that you are not known to ANY social services department as being an actual or potential risk to children; have not been disqualified or prohibited from fostering children or had any rights or powers in respect of any child vested in you assumed by a local authority; or have not had a child ordered to be removed from your care.

Signed: ____________________________ Dated: ___________

You are advised that under the provisions of the rehabilitation of offenders act 1974 (exceptions) order 1975 as amended by the rehabilitation of offenders act 1974(amendment 1986, you should declare all convictions (including spent convictions).

As part of the checking procedures for all applicants for posts of the nature, you are also advised that we reserve the right to make reference to the criminal records bureau or disclosure Scotland to verify the information given on this form.