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Annual Review of Data Capture Requirements for St John's Primary Academy
Childcare Disqualification Declaration Form
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Your Full Name *
Position in Academy *
Have you ever been convicted / cautioned of any violent or sexual offences against an adult? *
Have you ever been convicted / cautioned of any offences against a child?   *
Have you been barred by the DBS from working with children? *
Have you had any children taken into care?  *
Has a court order been made with regard to any children in your care? *
Have any of your children been / are currently subject to a child protection order? *
Have you been refused or had registration cancelled in relation to childcare or a children's home, or have you been disqualified from private fostering? *
Have you committed an offence overseas, which would constitute an offence under the disqualifications of 2018 regulations if it had been committed in the United Kingdom?
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If you have answered YES to any of the questions above, you should provide details below.  You may supply this information separately if you so wish, but you MUST do so without delay. 
Please provide the following: 
- Details of the order, restriction, conviction, caution etc.
- Dates of the order, restriction, conviction, caution etc 
- The relevant court(s) or body(ies)
You should also provide a copy of the relevant order, caution, conviction etc.
In relation to cautions/convictions a DBS certificate may be provided.
If no, please put N/A
 *
Declaration: 
In submitting 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 by Headteacher immediately of anything that effects my suitability including any cautions, warnings, convictions, orders or other determinations made that may render me disqualified from working with children. 

(Please note you may apply to Ofsted for a waiver against your disqualification) 

Respond by writing "I confirm all of the above" in the box below
 *
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