Self Declaration Form

Have you ever been charged with, cautioned or convicted in relation to any criminal offence not subject to DBS filtering rules*; or are you at present the subject of a criminal investigations/pending prosecution?
YesNo

Have you ever been the subject of a police investigation that did not lead to a criminal conviction not subject to DBS filtering rules*?
YesNo

To your knowledge have you ever had any allegation made against you which has been reported to and investigated by any Social Services/Social Work Department?
YesNo

* Information on DBS filtering rules can be found at www.gov.uk/government/publications/filtering-rules-for-criminal-record-check-certificates

Has there ever been any cause for concern regarding your behaviour towards children or vulnerable adults or have you ever had any disciplinary action taken against you in either a paid or voluntary position in regards to your behaviour towards children, young people or vulnerable adults?
YesNo

Have you had a DBS (formerly called CRB) carried out within the last three years?
YesNo

Declaration

To help us ensure that we are complying with current safeguarding legislation, please read the accompanying notes and complete the declaration.

I
of
confirm that I am not barred from working with children or vulnerable adult in regulated activities.

I consent to a DBS check should my placement make one necessary. I am aware that details of pending prosecutions, previous convictions, cautions or bindovers against me will be disclosed along with other relevant information which may be known to the police or the Disclosure and Barring Service.

I agree to inform the person responsible for processing DBS checks on behalf of Salford Elim Church if I am convicted of an offence or if become the subject of a police and/or social services/social work department investigation after taking up my role. I understand that failure to do so may lead to an immediate suspension of my position.

Signed

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