Self-Disclosure Form
This form must be completed by everyone wishing to work with children, young people or adults at risk (in voluntary or paid roles)
Full Name *
Your answer
Previous Name(s)
Your answer
Title *
Your answer
Date of Birth *
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Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)? For helpful information about which offences need to be declared see: https://www.gov.uk/government/publications/dbs-filtering-guidance/dbs-filtering-guide *
If yes, please give details
Your answer
Have you ever been known to any Local Authority children or adult safeguarding team, or the police as being a risk or potential risk to children, young people or adults at risk? *
If yes, please give details
Your answer
Have you ever been the subject of an investigation by any organisation or body due to concerns about your behaviour towards children or adults at risk? *
If yes, please give details
Your answer
Confirmation of Declaration: (Please read and tick each statement to show your agreement) *
Required
Please type your name to confirm you have given accurate answers to the best of your knowledge. *
Your answer
Today's Date *
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