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Self-declaration and disclosure form

Current Date

All information will be treated as confidential and managed in accordance with relevant data protection legislation and
guidance. You have a right of access to information held on you under the Data Protection Act 2018.

Employee information

Name *

Address *

Contact number(s) *

Email Address *

Date of birth *

Gender *MaleFemale

National Insurance number *

Identification *

Upload Image of Document *

No file chosen

Note: As the position you have applied for involves work with children and young people it is not covered by the provisions in the Rehabilitation of Offenders Act 1974. When answering questions 1 to 4 you must declare criminal convictions and/or cautions that are not ‘protected’ under the Exceptions Order (as amended). This includes UK, overseas and armed forces convictions, cautions and relevant service discipline convictions where it would be considered an equivalent offence in England and Wales.

Declaration of individual

1. Do you have any unspent conditional cautions or convictions under the Rehabilitation of Offenders Act 1974? *YESNO

Detail *

2. Do you have any adult cautions (simple or conditional) or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020? *YESNO

Detail *

3. Have you been formally charged with any other offence in any country which has not yet been disposed of? *YESNO

Detail *

4. Are you currently subject to any criminal investigations or pending prosecutions by the police in any country which may have a bearing on your suitability for this position? *YESNO

Detail *

5. Have you ever been known to any Children’s Services department or the police as being a risk or potential risk to children? *YESNO

Detail *

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

Detail *

7. Have you ever been dismissed for misconduct from any employment, volunteering, or other position previously held by you, in circumstances which may have bearing on your suitability for this position? *YESNO

Detail *

8. Are you currently subject to any fitness to practise investigations or proceedings by a regulatory, governing, or licensing body in any country, which may have bearing on your suitability for this position? *YESNO

Detail *

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 dismissal may result if information is not disclosed by me and subsequently comes to the organisation’s attention.

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.

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

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 organisations in circumstances where this is considered necessary to safeguard other children.

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