Safeguarding Declaration Form

CONFIDENTIAL DECLARATION

Applicants for posts (voluntary or paid) involving regular and direct contact with children and young people under 18 and/or vulnerable adults are required to complete this confidential declaration, as part of our safeguarding procedures.

This form will be treated as strictly confidential and, except under compulsion of law, will be seen only by those acting on behalf of the Young Lives Foundation in respect of the post for which you have applied. All forms will be kept securely under the terms of the Data Protection Act 1998. If you answer ‘yes’ to any question, please give details.

Please read the accompanying notes below the form before submission.

1. Criminal Offences

(a) Have you ever been convicted of a criminal offence (including any 'spent convictions' under the Rehabilitation of Offenders Act 1974)?*

Please tick  YES NO

If yes, please give details;

*All previous convictions, with the exception of technical motoring offences leading only to a fine, should be disclosed.

(b) Have you ever been cautioned by the police, given a reprimand or warning or bound over to keep the peace?

Please tick  YES NO

If yes, please give details;

(c) Are you at present under investigation or have court proceedings pending?

Please tick  YES NO

If yes, please give details;

2 .Children and Young People

(a) Have you ever been found by a court exercising civil jurisdiction (including matrimonial or family jurisdiction) to have caused significant harm to a child or young person under the age of 18 years, or put a child or young person at risk of significant harm?

Please tick  YES NO

If yes, please give details;

(b) Has your conduct ever caused or been likely to cause significant harm to a child or young person under the age of 18, or put a child or young person at risk of significant harm?

Please tick  YES NO

If yes, please give details;

(c) To your knowledge, has it ever been alleged that your conduct has resulted in any of those things?

Please tick  YES NO

If yes, please give details;

(d) Has a child in your care or for whom you have or had parental responsibility ever been removed from your care, been placed on the Child Protection Register or been the subject of a care order, a supervision order, a child assessment order or an emergency protection order under the Children Act 1989, or a similar order under other legislation?

Please tick  YES NO

If yes, please give details;

3. Vulnerable Adults

(a) Have you ever been found by a court exercising civil jurisdiction (including matrimonial or family jurisdiction) to have caused significant harm to a vulnerable adult or to have a vulnerable adult at risk of significant harm?

Please tick  YES NO

If yes, please give details;

(b) Has your conduct ever caused or been likely to cause significant harm to a vulnerable adult, or put a vulnerable adult at risk of significant harm?

Please tick  YES NO

If yes, please give details;

(c) To your knowledge, has it ever been alleged that your conduct has resulted in any of those things?

Please tick  YES NO

If yes, please give details;

4. Other Names/Addresses

(a) Have you, since the age of 18, ever been known by any name other than that given below?

Please tick  YES NO

If yes, please give other names below;

(b) Have you, during the past five years, had any home address other than that given below?

Please tick  YES NO

If yes, please state previous addresses here:

5. Disqualification by Association

To the best of your knowledge, is anyone in your household* disqualified from working with children under the Regulations?

(*household – includes family, lodgers, house-sharers, household employees etc)

Please tick  YES NO

This means does anyone in your household have an Order or Restriction against them set out in question 1 or have they been cautioned, reprimanded, given a warning for or convicted of any offence in question 2 or 3 or of the Childcare (Disqualification) Regulations 2009.

Declaration

I declare that the above information (and that on any of the attached sheets) is, to the best of my knowledge, accurate and complete and I consent to the Young Lives Foundation making enquiries to verify the information.  YES

Should any of the required information change, I shall inform the Young Lives Foundation immediately.  YES

Signed (your full name):

Date of Birth (dd/mm/yyyy): / /

Home address:

Please type out the following characters:

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Definitions

Vulnerable Adult | Vulnerable adult refers to a person over the age of 18 who is or may be suffering from mental ill-health, learning difficulty, physical disability, age or illness and who is or may be unable to protect him/herself from harm or exploitation.

Significant Harm | Significant harm involves serious ill-treatment of any kind including neglect, physical, emotional or sexual abuse, or impairment of physical or mental health development.

Questions 1(a) and 1(b):
Declare all convictions, cautions, warnings or reprimands. Posts where the person is working or coming into contact with children/young people or vulnerable adults are exempt from the Rehabilitation of Offenders Act 1974 so that all spent convictions must be declared.

Any technical motoring offences dealt with by fine do not need to be declared.

Question 1(c):
Declare if you are at present under investigation by the police, social services or an employer.

Question 2(a):
You must declare any finding of fact by a civil court that your actions have significantly harmed a child or young person. Declare any court orders made on this basis.

Question 2(b):
Make any statement you wish regarding any incident you wish to declare.

Question 2(c):
Declare any allegations made against you, however long ago, that you have significantly harmed a child or young person. Any allegation must be declared that has been investigated by the police, social services, employer or voluntary body. Checks will be made with the relevant authorities.

Question 3(a):
You must declare any finding of fact by a civil court that your actions have significantly
harmed a vulnerable adult. Declare any court orders made on this basis.

Question 3(b):
Make any statement you wish regarding any incident you wish to declare.

Question 3(c):
Declare any allegations made against you, however long ago, that you have significantly harmed a vulnerable adult. Any allegation must be declared that has been investigated by the police, social services, employer or voluntary body. Checks will be made with the relevant authorities.

Some of the information requested on the form will be checked with the Criminal Records Bureau and a check with the Disclosure & Barring Service. All Information received will be carefully assessed to decide whether it is relevant to the post applied for and will only be used for the purpose of protecting children and young people and/or vulnerable adults.

Question 5:
The Regulations relate to the The Childcare (Disqualification) Regulations 2009 and the Childcare Act 2006:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414345/disqual_stat-guidance_Feb_15__3_.pdf