County Championships Team Event Entry Form

Self Disclosure Form

To be completed at the same time as the application form (if required): Private and Confidential. For roles involving contact with children (under 18 year olds). 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 1998.
Part One

For completion by the organisation:
Name

First NameLast Name
Contact Address

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Phone Number
Please enter a valid phone number.Format: 00000000000.
Contact Email
example@example.com
Date of Birth

MonthDayYear
Gender
Identification

I confirm that I have seen identification documents relating to this person, and I confirm to the best of my ability that these are accurate.
UK Passport and Issuing Office:
UK Driving Licence Number (with picture):
Plus: National Insurance Card or current Work Permit Number
Signature of authorised Employing Officer
Name

First NameLast Name
Date

MonthDayYear
Date
Part Two

NOTE: If the role you have applied for involves frequent or regular contact with or responsibility for children you will also be required to provide a valid DBS (Disclosure and Barring Service) certificate which will provide details of criminal convictions; this may also include a Barring List check depending on the nature of the role (see organisational guidance about eligibility for DBS checks). For completion by the person named in Part One.
Have you ever been known to any Children’s Services department as being a risk or potential risk to children? (if

YesNo
Yes, please provide further information:
Have you been the subject of any disciplinary investigation and/or sanction by any organisation due to concerns about your behaviour towards children?

YesNo
Yes, please provide further information:
How did the Accident occur: [include: names; telephone numbers; etc.]
Confirmation of Declaration (tick box below)

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here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or dismissal may result if information is not disclosed by me and subsequently come to the organisation’s attention.In accordance with the organisation’s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.
Signature
Name

First NameLast Name
Date

MonthDayYear
Date
County Welfare Officer

I have seen and checked the above responses, if any of the boxes above are ticked YES, I have referred this form to England Golf Governance Department for a risk assessment and advice.
Signature (Welfare Officer)
Date

MonthDayYear
Date
Should be Empty:

Self Disclosure Form

Part One

Identification

Part Two