APPLICATION/RENEWAL* FOR CHAPERONE’S LICENCE

*(delete as appropriate)

Children and Young Persons Act, 1963 Children (Performance) Regulations, 1968

LICENCE NO:______EXPIRY DATE: ______LICENCING AUTHORITY: ______

“The Licensing Authority shall not approve a chaperone unless they are satisfied that she/he is suitable and competent.” ( Regulation12(2),Children(Performance)Regulations1968).

Last Name: ______First Names: ______

Known as: ______Mr/Mrs/Miss/Ms/Other: ______

Date of Birth: ______Place of Birth: ______

Full name at Birth: ______

First Language: ______Ethnicity: ______Religion: ______

Address: ______

______Postcode______

Telephone No: ______Mobile No: ______

E-Mail Address: ______

How long at that address: ______(If less than 5 years please supply previous addresses).

1. 2. 3.

I give my permission for the Local Authority to make necessary checks with Social Care Services to ascertain my suitability to be licensed as a Chaperone:

Please Tick

Child Employment Team,

Endeavour House,

8 Russell Road,

Ipswich

IP1 2BX

Tel: 01473 265195

Present Employer:
Address:
Postcode:
Type of Work:
Have you ever previously been approved as a Licensed Chaperone? Licence Number & Expiry Date if applicable
Do you have a current First Aid qualification? /
YES
Date issued: /
NO
Safeguarding certificate? /
YES
Date issued: / NO
Do you have a valid driving licence? (Full or Provisional) / YES / NO
Do you have any health condition that might have a bearing on your application? If so, give details.
New Applicants: Have you read the Duties of a Licenced Chaperone? / Please indicate: YES / NO

ALL APPLICANTS PLEASE NOTE: ENHANCED DISCLOSURES

For those applicants who are Volunteers and do not already hold an Enhanced Disclosure Certificate for the Child Workforce, Suffolk County Council will provide this service as part of the Chaperone process.

Applicants who already hold an Enhanced Disclosure Certificate for the Child Workforce can only use this Certificate if subscribed to the DBS Update Service and provide Suffolk County Council with a photocopy of it at time of application.

Have you subscribed to the DBS Update Service? / YES / NO
If YES, please tick the box below:
I give my permission for the Local Authority to make necessary checks with the Disclosure and Barring Service:

Please Tick
Please note you will need to supply a photocopy of your Enhanced Disclosure with this application form Only if you have Subscribed to the DBS Update Service.
Name of Dance/ Theatre Group linked to this application.
Do you wish for your name to appear on a “List of the Local Authority Approved Chaperones” to pass to other Theatre/Dance groups or Agencies? / Please indicate: YES / NO

DECLARATION TO BE SIGNED BY PERSON(S) RESPONSIBLE FOR SAFEGUARDING CHILDREN FOR THE GROUP/SOCIETY

I hereby declare that the above mentioned person:
a) is suitable and competent to exercise proper care and control of a child/children of the age and sex within their control within the permitted ratio (1:12)
b) will not be prevented from carrying out duties towards the child/children in their care by duties/responsibilities towards other children at the place of performance.
**Not to be signed by Applicant – Personal Reference required if owner/principal of Dance/Theatre Group
**Signed:
PRINT NAME:
Position held:
Owner of Dance/Theatre Group will need to supply an email address for a Personal Reference / Dated:
Email Address:

Do you have any criminal convictions and/or cautions, pending or otherwise, excluding those spent under the Rehabilitation of Offenders Act 1974?

Yes No Please Tick

If Yes, please provide further details below:

Date / Court / police station / Offence / Result (for convictions)

DECLARATION TO BE SIGNED BY THE APPLICANT

I hereby declare that the above information is true, to the best of my knowledge. I understand that I would be liable to prosecution if I wilfully stated in my application anything which I knew to be false or did not believe to be true.
Signed:
This is not an online application and a signature is required / Dated:
This form should be returned with the following documents:

2 X passport sized portrait photographs with your name on the back*
*These do not have to be passport quality (just passport sized) – can be printed from PC on ordinary paper
A photocopy of your DBS Enhanced Certificate for the Child Workforce Only if you have subscribed to the DBS Update Service
Child Employment Team
Endeavour House
8 Russell Road
Ipswich IP1 2BX
Telephone: 01473 265195
Website: www.suffolk.gov.uk/childemployment
Email:

CL/2017/V4