Diocese of Down and Connor
Use of Parish Centre and St. Patrick's Hall by Parish Groups and Ministries
Details of Parish Group or Ministry
Will your Group be working directly with Children / Young People? (as defined in Section B)
Yes
No
Will your Group be working directly with "Adults at Risk of Harm" or "In Need of Protection"? (as defined in Section B)
Yes
No
Would you like to view the contents of Section B - Safeguarding?
Yes
No
Section B Safeguarding
If you answered 'YES' to either of the questions above Please provide details of the Person Responsible for Safeguarding in the Group
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Details of Premises and Room(s) Required
Premises Required
Parish Centre Newcastle
St. Patrick's Hall Bryansford
Your Preferred Room, Date and Time of Event
Purpose of Use
Estimated Number of People Attending Event
Signature of Group Leader / Contact
Date of Signature
Does Your Activity involve working with any of the Vulnerable Groups as defined in Section B
Yes
No
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Working with "Vulnerable Groups" as defined in Section B
If you answer Yes to the question which follow, you Must complete the entire section below.
Address Details of 1st Person In Charge of Activity During Event
Name of Person
Street Address
Town
County
Post Code
Address Details of 2nd Person In Charge of Activity During Event
Name of Person
Street Address
Town
County
Post Code
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WORKING WITH VULNERABLE GROUPS
Do you confirm you have a Safeguarding Policy for Vulnerable Groups
Yes
Do you confirm you have a Designated Person for Safeguarding Vulnerable Groups
Yes
What is the name of the Designated Person for Safeguarding Vulnerable Groups
What is the mobile number of the Designated Person for Safeguarding Vulnerable Groups
-
Area Code
Phone Number
Do you have a written Code of Conduct for You and All Volunteers
Yes
Do you ensure that You and All Volunteers have access to appropriate training in Safeguarding Vulnerable Groups
Yes
Do you ensure that You and All Volunteers have access to appropriate training in Safeguarding Vulnerable Groups
Yes
What is the name of Your Training Provider
Have You and all your Volunteers been Access NI vetted for this activity?
Yes
Do you have appropriate Recruitment / Appointment procedures for all your volunteers?
Completing an application form
Obtaining references
Do you have a register of Children/Young People and/or Adults at Risk of Harm/or Adults in need or Protection who attend your activity to include details of their name, address, date of birth and next of kin?
Yes
No
Do you keep a list of names of all volunteers with regular and direct contact with Children/Young People and/or Adults at Risk of Harm and / or Adults in Need of Protection that you update as the need arises?
Yes
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Section A General Terms of Use
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Section B Safeguarding
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Section C Insurance
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Section D Declaration
I the Group Leader declare that:
I have read and agree to abide by the conditions and 'Regulations as to Use' set out in this Licence Agreement. The answers given above, and in particular in Section B (Safeguarding) to the best of my knowledge, are true and complete and are in place.
Agreed
I understand and accept the commitment ·of the Diocese of Down and Connor to ensure the safety and protection of Children/Young People, Adults at Risk of Harm and Adults in Need of Protection while using their facilities.
Agreed
I will ensure that I and all associated with the provision of the activity will work to the Standards of Good Practice outlined in our organisation's Safeguarding Policy for Children/Young People and/or Adults at Risk of Harm and/or Adults in Need of Protection. Our policy will not be in contravention of the Down and Connor Safeguarding Policies or any Parish Codes of Conduct.
Agreed
I understand that this agreement is conditional upon me keeping to the Down and Connor Diocesan Safeguarding Policies and Procedures, any Parish Codes of Conduct and the Regulations as to Use.
Agreed
I understand that the agreement can be terminated if we fail to comply with them.
Agreed
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Signature and Details of Group Leader
Details of Group Leader
Signature of Group Leader
Date of Signature
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Submit Form
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