Disqualification Declaration

Please enter your full name:*

Prefix First Last

Have any orders or other determinations related to childcare been made in respect of you?*

Yes
No

Have any orders or other determinations related to childcare been made in respect of a child in your care?*

Yes
No

Have any orders or other determinations been made which prevents you from being registered in relation to child care, children’s homes or fostering?*

Yes
No

Have you ever been cautioned, reprimanded, given a warning for or convicted of: Any offence against or involving a child (a person under the age of 18)?*

Yes
No

Have you ever been cautioned, reprimanded, given a warning for or convicted of: Any violent or sexual offence against an adult?*

Yes
No

Have you ever been cautioned, reprimanded, given a warning for or convicted of: Any offence under the Sexual Offences Act?*

Yes
No

Have you ever been cautioned, reprimanded, given a warning for or convicted of any similar offence in another country?*

Yes
No

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

Yes
No

Household includes family, lodgers, house-sharers, household employees, etc. To the best of your knowledge, does anyone in any of these categories have an Order or Restriction against them or have they been cautioned, reprimanded, given a warning for or convicted of any offence?

If you have answered YES to any of the questions above you should provide details in the section below in respect of yourself, or where relevant the member of your household. Details of the order, restriction, conviction caution etc / The date(s) of these / The relevant court(s) or body(ies)

If you did not select yes to any of the answers above, please skip this section.

Declaration in E-signing this form: I confirm that the information provided is true to the best of my knowledge and that I understand my responsibilities to safeguard children. I understand that I must notify my headteacher immediately of anything that affects my suitability including any cautions, warnings, convictions, orders or other determinations made in respect of me or a member of my household that would render me disqualified from working with children. I confirm all the information I have provided today is accurate:*

Yes
No

Full Name:*

First Last

Today's Date*

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