Self-Disclosure Form

In accordance with Safer Recruitment guidelines, before you can start tutoring, you are required to fill out a self-disclosure form, which you can find here.

Name

First Name

Last Name

Previous Name(s) (If applicable)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone No.

(###)

###

####

Date of Birth

YYYY

Gender

Have you ever been known to any Children’s Services department or Police as being a risk or potential risk to children?

If yes, please provide further information:

Have you been the subject of any investigation and/or sanction by any organisation or body due to concerns about your behaviour towards children?

If yes, please provide further information and include details of the outcome:

Have you ever been the subject of disciplinary sanctions or been asked to leave employment or voluntary activity due to inappropriate behaviour towards children?

If yes, please provide further information:

Do you have any unspent convictions or conditional cautions?

Do you have any spent adult cautions (simple or conditional) or convictions that are not ‘protected’ as defined by either: • the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended in England, Scotland and Wales • or the Rehabilitation of Offenders (Northern Ireland) Order 1978 as amended in Northern Ireland?

Do you have any overseas convictions?

If yes, please provide further information:

Confirmation of declaration (tick box below)

I agree that the information provided here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or disciplinary action may be taken if information is not disclosed by me and subsequently come to the organisation’s attention. In accordance with the organisation’s procedures if required I agree to provide a valid criminal record certificate and consent to the organisation clarifying any information provided on the disclosure with the agencies providing it. I agree to inform the organisation within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children or young people. I understand that the information contained on this form, the results of the DBS check and information supplied by third parties may be supplied by the organisation to other persons or organisations in circumstances where this is considered necessary to safeguard children.

I agree

Print Name

Today's Date

YYYY