Self Declaration and Disclosure Form

Self Declaration and Disclosure Form

Private and Confidential
All information will be treated as confidential and managed in accordance with relevant data protection legislation and guidance.
Your details
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town/CityBorough

Postcode
Date of birth*

DayMonthYear
Gender*

FemaleMaleNon-binaryPrefer not to sayOther
Phone Number*
for example: 0161 123 3456
Declaration

If the answer is 'Yes' to any of the questions on this form, please provide further details*

	Yes	No	Additional Comments
1. Do you have any unspent conditional cautions or convictions under the Rehabilitation of Offenders Act 1974?
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?
3. Have you been formally charged with any other offence in any country which has not yet been disposed of?
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?
5. Have you ever been known to any Children’s Services department or the police as being a risk or potential risk to children?
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?
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?
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?

Your details