Self Disclosure Form

Self-Disclosure Form

Required for ALL volunteers working with/or in contact with children and vulnerable adults as part of HDC Leisure Development activities. Please return this form as soon as possible. It is a necessary procedure that must now be followed by all CONFIDENTIAL
Name	First Name	Second Name	Other Name(s)

Address
Postcode
Date of birth
Place of birth
Have you ever been convicted of a criminal offence or been the subject of a Caution or Bound Over Order?	Yes No
If "Yes" Please state the nature and date (s)of these offence (s)
Have you ever been subject to any disiplinary action or sanctions relating to child or vulnerable adult abuse?	Yes No
If "Yes" please give details
I certify that; I have NEVER been disqualified or prohibited from working with children or vulnerable adults. I am not known by ANY social services department as being an actual or potential risk to children or vulnerable adults. I have NEVER been disqualified or prohibited from fostering children or vulnerable adults. I have NOT had any rights or powers in respect of any child or vulnerable adult removed from me by a local authority. I have NOT had a child or vulnerable adult removed from my care. By clicking SUBMIT I certify that all of the above statements are correct

You are advised that under the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Amendment) 1986, you should declare all convictions (including spent convictions) As part of the checking procedures for all applicants for posts of this nature, you are also advised that we reserve the right to make reference to the local authority social services department and police records to verify the information given on this form.

Required for ALL volunteers working with/or in contact with children and vulnerable adults as part of HDC Leisure Development activities.

Please return this form as soon as possible. It is a necessary procedure that must now be followed by all

CONFIDENTIAL

Name

First Name

Second Name

Other Name(s)

Address

Postcode

Date of birth

Place of birth

Have you ever been convicted of a criminal offence or been the subject of a Caution or Bound Over Order?

Yes
No

Have you ever been subject to any disiplinary action or sanctions relating to child or vulnerable adult abuse?

Yes
No

I certify that;

I have NEVER been disqualified or prohibited from working with children or vulnerable adults.
I am not known by ANY social services department as being an actual or potential risk to children or vulnerable adults.
I have NEVER been disqualified or prohibited from fostering children or vulnerable adults.
I have NOT had any rights or powers in respect of any child or vulnerable adult removed from me by a local authority.
I have NOT had a child or vulnerable adult removed from my care.

By clicking SUBMIT I certify that all of the above statements are correct

You are advised that under the provisions of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Amendment) 1986, you should declare all convictions (including spent convictions)

As part of the checking procedures for all applicants for posts of this nature, you are also advised that we reserve the right to make reference to the local authority social services department and police records to verify the information given on this form.