Page 0018

Part Two: (FOR THE COMPLETION BY THE INDIVIDUAL NAMED IN PART ONE):

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).

Have you ever been known to any Children's Services

Have you ever been known to any Children's Services

department as being a risk or potential risk to children?

department as being a risk or potential risk to children?

YES / NO

(if Yes, please provide

further information below):

..........................................................................................................................................................................................

..........................................................................................................................................................................................

Have you been the subject of any disciplinary investigation

and/or sanction by any organisation due to concerns about

your behaviour towards children?

YES / NO

(if Yes, please provide

further information below):

..........................................................................................................................................................................................

..........................................................................................................................................................................................

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withdrawn or dismissal may result if information is not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.

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