Self-Disclosure FormPRIVATE & CONFIDENTIAL
To be completed at the same time as the application form:
For roles involving contact with children (under 18 year olds)
All information will be treated as confidential and managed in accordance with relevant data protection legislation and guidance. You have a right of access to information held on you under the Data Protection Act 1998.
YES
NO
YES
NO
Confirmation of Declaration
A. 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here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or dismissal may result if information is not disclosed by me and subsequently come to the organisation's attention.
B. In accordance with the organisation's procedures if required I agree to provide a valid DBS certificate and consent to the organisation clarifying any information provided on the disclosure with the agencies providing it.
C. 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.
D. I understand that the information contained in 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 other children.
A.
B.
C.
D.
By entering my name in the box below and submitting this form I am intending this form to have the same effect as if a paper copy had been completed and signed by me
Confirm
