Failure to provide true and accurate information may lead to disqualification and the immediate withdrawal of the
1. Have you ever been the subject of any Child Protection concern, either in your work or personal life, or
disciplinary action, including any which time is expired? Yes / No
2. I have read and understood all the questions on the application form.
3. I am not subject to any immigration controls or restrictions which prohibit my undertaking work in the UK.
4. I understand that:
I. Under the Rehabilitation of Offenders Act 1974, if successful, I will be asked to sign a written
declaration stating any cautions, bind-overs, prosecutions or convictions which are either on my record
or pending, even if they would be regarded as ‘spent’ under the Act. I understand that, if successful, I
may be questioned about the content of the declaration. I further understand that failure to disclose
such convictions may result in the immediate withdrawal of the licence.
II. Under Home Office guidelines regarding the protection of children, I will be asked to agree to a check
being made by the Criminal Records Bureau about the existence and content of a criminal record.
III. In accordance with the Data Protection Act, the personal details submitted with this application form
will be used only for selection and interview procedures and for employment records if successful.
IV. Providing false information is an offence and could result in my application being rejected or withdrawal
of the Chaperone Licence and possible referral to the police.
5. The information I have given on this form is true and accurate to the best of my knowledge.
6. If my application for approval as a Chaperone is successful, I agree to notify Rochdale Borough Council
within seven days of:
i. Any arrest for any offence, or conviction of any offence (excluding fixed penalty fines) in a court of law
whether in the United Kingdom or elsewhere.
ii. Any notifiable illness
iii. Any health condition or debility that may affect my ability to carry out the duties of a Chaperone
iv. Any change of name or address.
SIGNED ___________________________________ DATE: ________________________
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