PVG Self Declaration Form

Scottish Gymnastics U16 Self Declaration Form for Regulated Work with Children
Scottish Gymnastics and its member clubs are committed to the protection of children involved in gymnastics and have a duty to ensure the suitability of any individual applying to do regulated work (paid or voluntary) with children.

Therefore, before you can be appointed, even to an unpaid position within your club, Scottish Gymnastics must check that you are suitable to do this type of work.
Applicant Name*

First NameLast Name
Club*
Clubs Safeguarding Email*
example@example.com
Role in Club*
Coach/helper, etc.
Under the Rehabilitation of Offenders Act (Exclusions and Exceptions) (Scotland) Amendment Order 2015 applicants are required to disclose any unspent convictions or cautions and any spent convictions for offences included in Schedule A1 ‘Offences which must always be disclosed’.

For more information, please check the documents below:

Details of Schedule A1 Offence

Applicants are not required to disclose spent convictions for offences included in schedule B1 ‘Offences which are to be disclosed subject to rules’ until such time as they are included in a higher level disclosure issued by Disclosure Scotland.

Details of Schedule B1 Offences

Information provided is confidential. It will be managed according to our data protection policy and will not be shared outside of Scottish Gymnastics officials responsible for making safe appointment decisions.
Title*
Name*

First NameLast Name
Postal Address*
Date of Birth*

DayMonthYear
Date
Contact Number*
Email*
example@example.com
Section 1 - Unspent convictions/cautions

These must be disclosed, as listed in the documents above.
1. Do you have any unspent convictions?*

YesNo
If yes, please give details
a) Please give the date and details of all the offence(s) with which you were charged, the sentence that you received and the court where your case(s) was heard. b) Please outline the circumstances that led to your offence(s). c) Please give details of the sentence imposed and how it was completed (for example paid fine as required) include information on conditions attached to your probation/community service/supervised attendance order.
Section 2 - Details of any disciplinary action in relation to children
2. Have you been disciplined because of inappropriate behaviour towards a child, which may have harmed them or put them at risk of harm?*

YesNo
If yes, please give details
Section 3 – Relevant non-conviction information

Please note that this section does not require details of any spent alternatives to prosecution, e.g. police warnings or procurator fiscal warnings.
3.1 Do you have any relevant non-conviction information (including any police information)?*

YesNo
If you answered yes please give details of any investigations and outline the reasons and circumstances and disposal if known.
3.2 Are you, or have you ever been, known to any social work department/social services department as an actual or potential risk to children?*

YesNo
If you answered yes please give details.
Section 4 – Other relevant information
Please give details of any other relevant information which you think we should be aware of when considering your application:
Section 5 – Protection of Vulnerable Groups (Scotland) Act 2007
Before signing the declaration below, please read the following notes on the Protection of Vulnerable Groups (Scotland) Act 2007 (PVG Act):

1. It is an offence to do, or to seek or agree to do any regulated work (paid or unpaid) from which you are barred.

2. Section 35 of the same act makes it an offence for the club to offer regulated work (paid or unpaid) to someone who is barred from that work.

3. A person is barred from regulated work with children if they are:

· the subject of an automatic listing (under section 14 of the PVG Act).

· included on the PVG Children’s List and/or the Disclosure and Barring Service
Children’s List which covers the rest of the UK.

· considered for listing while information on their suitability is assessed.
Please choose the option which applies to you*

I confirm that I am not barred from regulated work with children as setout in sections 14 and 15 of the PVG Act, nor am I under consideration for listing as set out in section 12 of the same Act.I am under consideration for listing
Section 6 – Declaration
1. I hereby declare and represent that, except for as disclosed above, I have not at any time, whether in the United Kingdom or abroad, been found guilty and sentenced by a court for a criminal offence.

2. I agree to inform Scottish Gymnastics if I am convicted of an offence while a member of staff/volunteer. I understand that failure to do so may lead to the immediate suspension of my work (paid or unpaid) for the club and/or the termination of my services.

3. If I become considered for listing, I understand this will result in precautionary suspension.

4. I certify that all information contained in this form is true and correct to the best of my knowledge and realise that false information or omissions may lead to dismissal. I understand that deliberately giving false information can result in prosecution.
Applicant Signature*
Please type your full name to confirm the above statements
Date*

DayMonthYear
Parent/Guardian Signature*
Please type your full name to confirm the above statements
Date*

DayMonthYear
Should be Empty:

Scottish Gymnastics U16 Self Declaration Form for Regulated Work with Children

Section 1 - Unspent convictions/cautions

Section 2 - Details of any disciplinary action in relation to children

Section 3 – Relevant non-conviction information

Section 4 – Other relevant information

Section 5 – Protection of Vulnerable Groups (Scotland) Act 2007

Section 6 – Declaration