Self-Disclosure Form

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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 *

Previous Name(s)

Title *

Date of Birth *

YYYY

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 *

Yes

If yes, please give details

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? *

Yes

If yes, please give details

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? *

Yes

If yes, please give details

Confirmation of Declaration: (Please read and tick each statement to show your agreement) *

I agree that the information provided here may be processed for recruitment purposes (both to employed and voluntary posts). I understand that the offer of employment or voluntary work could be withdrawn if information is not disclosed by me and subsequently comes to the church’s attention.

In accordance with the Church Safeguarding Policy Handbook I will provide a valid DBS Certificate and consent to the Baptist Union of Great Britain, on behalf of the church, clarifying any information provided on it with the agencies providing it.

I will inform the Church within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children, young people or adults at risk.

I understand that the information in this form, the results of the DBS check and information supplied by third parties may be passed to other persons or organisations in circumstances where this is considered necessary to safeguard children, young people or adults at risk.

Required

Please type your name to confirm you have given accurate answers to the best of your knowledge. *

Today's Date *

YYYY

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