Chaperone Licence Application

THE CHILDREN (PERFORMANCE & ACTIVITIESENGLAND) REGULATIONS 2014
APPLICATION FOR APPROVAL AS A CHAPERONE
“The licensing authority must not approve a person as a chaperone unless it is satisfied that the person is suitable and competent"

Regulation 15(4), The Children (Performance and Activities (England) Regulation 2014)
All information given in this application will be treated in confidence other than information relating to criminal offences.
Please Select One*
Surname: (BLOCK CAPITALS*
First Names (BLOCK CAPITALS)*
Date of Birth*

DayMonthYear
Date
Place of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone No (inc STD code)*
Mobile No*
Email Address*
example@example.com
How long have you lived at your current address?*
If less than 5 years please list previous address(es), including Post Code*
National Insurance Number*
Present Employer*
Employer Address*
What Type of Work Do You Do?*
Professional Qualifications*
Additional Information
Tick if you have you ever been approved as a Chaperone/matron.

YES
If yes, when and by which Authority?
Tick if you are/were you a registered childminder or foster carer.

YES
If yes, when and by which Authority?
Tick if you have recieved First Aid Training.

YES
Upload a copy of your First Aid Certificate Below

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Tick if you have undertaken Safeguarding training in the last 3 years?*

YES
Upload a copy of your Safeguarding Certificate Below*

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The Authority is entitled, under arrangements introduced for the protection of children, to check with the criminal Records Bureau for the existence of any criminal record. Therefore you will be required to complete a disclosure form to enable an Enhanced check to be undertaken.

Please see Council Rehabilitation of Offenders Act 1974 convictions and ‘Spent’ Convictions of a Criminal Nature.

The work for which you are applying will entail regular contact with children and is exempt from the rehabilitation of Offenders Act 1974. Therefore, you are required to declare any convictions, cautions, bind-over or prosecutions you may have, even if they would otherwise be regarded as ‘spent’ under this Act.
Have you ever been convicted of any criminal offence?*

YesNo
If YES, please specify the date of the conviction, Court, nature of offence and sentence imposed.
You will also require to declare any cautions, bind-overs or prosecutions you may have, even if they would otherwise be regarded as ‘spent’ under the Act. Please enter details below
Please give the name, address, email address, telephone number and relationship to you of two responsible persons who would be prepared to provide a reference as to your suitability to be a chaperone. References should be from separate sources and not from the same organisation or employer e.g. current or most recent employer, a person who has knowledge of and can comment on your work with children, someone who knows you in a professional capacity. Reference cannot be accepted from a spouse of family relation or from someone with whom you live.
REFERENCE 1
Name*
Full Address (inc post code)*
Email address*
example@example.com
Telephone Number*
Occupation*
Relationship to applicant*
REFERENCE 2
Name*
Full Address (inc post code)*
Email address*
example@example.com
Telephone Number*
Occupation*
Relationship to applicant*
Give below details of any relevant experience of working with children in either a voluntary of professional capacity*
South Tyneside Council is committed to safeguarding and promoting the welfare of children and young people and expects all staff and volunteers to share this commitment.
If approved, do you agree to your details being put on a list of Local Authority approved Chaperones that may be given to amateur groups and dance schools?

YesNo
DECLARATION TO BE SIGNED BY APPLICANT
1. I hereby declare that the above information is true, to the best of my knowledge. I understand that the Authority will need to make further enquiries regarding any possible convictions I may have. I understand that the Authority will make enquiries of partner agencies regarding my suitability to carry out the duties and responsibilities of a Chaperone.

2. I also declare that I have read and understood the guidance documentation on the duties and responsibilities of Chaperones. I am fit and able to undertake all the duties detailed within the guidance document. I am not disqualified from work with children or subject to sanctions imposed by a regulatory or professional body e.g. Ofsted.

3. I also declare that I will notify South Tyneside Council of any change of name or address or any change in circumstances that may affect any ability to effectively carry out the duties and responsibilities pf a Chaperone.

4. I also declare that I will have completed South Tyneside Safeguarding Children Board e-learning course for Safeguarding Children or equivalent prior to the processing of my application.

5. I also agree to my information being shared as and when necessary as part of my application.
Please upload a head and shoulders image of you. This will be used on your offcial licence.*

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Please Sign Below

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THE CHILDREN (PERFORMANCE & ACTIVITIESENGLAND) REGULATIONS 2014

APPLICATION FOR APPROVAL AS A CHAPERONE

Additional Information

REFERENCE 1

REFERENCE 2

DECLARATION TO BE SIGNED BY APPLICANT