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Chipstead Place Lawn Tennis Club

CPF 3.1.5 - Self declaration form

For people working with children. Please return to the requesting club or body.

 

Full name

(please print)

 

 

Any previous or other names

 

 

Date &

place of birth

 

 

 

Current address

 

 

 

Previous address (if you have been at your current address for less than 5 years)

 

 

 

 

 

Have you been convicted of any offence or had a conviction or been bound over; or is a prosecution pending related to: children, any offence under the Sexual Offences Act, any offence involving violence of any nature or drug related offences?  (Note: You are advised that you should declare ALL convictions including ‘spent’ convictions where working with children.)

 

Yes

 

If you  have ticked this box please provide details below

 No

 

 

 

Full details if answered “yes” above

 

 

 

 

Are you a person known to ANY social services department as being an actual or potential risk to children, vulnerable adults or any other people?

 

Yes

 

If you  have ticked this box please provide details below

 No

 

 

 

Full details if answered “yes” above

 

 

 

 

Have you ever had a sanction imposed against you or been disciplined in any way for any matter relating to child abuse, sexual offences, violence or the use of drugs?

 

Yes

 

If you  have ticked this box please provide details below

 No

 

 

 

Full details if answered “yes” above

 

 

 

Please list your current club and the last three (if applicable) with which you have been associated:

 

Club name & address

 

 

 

 

Club name & address

 

 

 

 

Club name & address

 

 

 

 

Club name & address

 

 

 

 

 

Please supply the names and addresses of two referees whom the LTA can contact regarding your suitability to work with children or vulnerable adults (these must not be a partner or relation).

 

Full name

Full name

 

Address

 

 

 

Address

Phone no.

 

Phone no.

Relationship to referee

 

 

Relationship to referee

How long have you been known to the referee?

 

 

How long have you been known to the referee?

 

CONSENT – please read carefully

I hereby consent to the requesting body undertaking criminal record and/or social services and other relevant third party checks in connection with this self-declaration in line with LTA policy on the safeguarding of children.  I understand that the information contained on this form, the results of any police and/or social services checks and information supplied by third parties will be recorded by the requesting body and/or the LTA. I understand that, if I continue to be associated with the requesting body, I must inform this body immediately of any changes relating to the questions above.  I understand that action may be taken should I complete this form with false information or with information I know or believe to be incorrect.  I understand that I have the right of access to information held on me and other rights under the Data Protection Act 1984.

 

Signed

 

Date

 

 

 

 

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