CH(F)24(K)CH(F)24
Information required forchecksand
references(Family & Friends Assessment)
Main Applicant's
Full Name /
Second Applicant's
Full Name /
Address /
PostTown /
Postcode / / Telephone /
Email /
I / We have lived at this address since (mm/yyyy) / /
Applicants’ Signature(s) /
OTHER NAMES USED
Have either of you ever been known by any other names? / Yes / / No /
Surname /
Forenames /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Surname /
Forenames /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Surname /
Forenames /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Surname /
Forenames /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Please use the continuation sheet on page 10 if necessary
Please supply the name and address of your General Practitioner. If you are having a joint assessment with your spouse or partner and you have separate GPs, please give two sets of details and state whose is which: if you both have the same GP, please give only one.G.P. of :(state name or write "both") /
Name of G.P. /
Surgery /
Address /
PostTown /
Postcode / / Telephone /
G.P. of:(if not joint) /
Name of G.P. /
Surgery /
Address /
PostTown /
Postcode / / Telephone /
GP Check(s) sent:………………Inits:………………
We also require the names and addresses of sixpersonal referees who know you well and can comment knowledgably on your abilities, particularly around childcare. Please obtain their agreement before passing on their details.NB. These should not be your GP or employer and only two may be family members or relatives.
Name of Referee (1) /
Address /
PostTown /
Postcode / / Telephone /
Name of Referee (2) /
Address /
PostTown /
Postcode / / Telephone /
Name of Referee (3) /
Address /
PostTown /
Postcode / / Telephone /
Name of Referee (4) /
Address /
PostTown /
Postcode / / Telephone /
Name of Referee (5) /
Address /
PostTown /
Postcode / / Telephone /
Name of Referee (6) /
Address /
PostTown /
Postcode / / Telephone /
Pers Ref 1 sent: ………………Inits:………… Pers Ref 2 sent: ………………Inits:…………
Pers Ref 3 sent: ………………Inits:………… Pers Ref 4 sent: ………………Inits:…………
Pers Ref 5 sent: ………………Inits:………… Pers Ref 6 sent: ………………Inits:…………
If you are currently, or have been recently, employed, please supply the name of your manager or supervisor and the business name and address of your employer.Applicant /
Manager/Supervisor /
Name of Business/Company /
Address /
PostTown /
Postcode / / Telephone /
Continued…
Applicant / Manager/Supervisor /
Name of Business/Company /
Address /
PostTown /
Postcode / / Telephone /
Employer Check(s) sent: (1) ………………Inits: ………………(2) ..………………Inits: ………………
If either of you has been previously married or had significant long-term relationship(s), please supply the name(s) and address(es) of your former partner(s), the dates of the relationship(s) and the name(s) and date(s) of birth of any children of the relationship.Former Partner of :(state name) /
Name of Former Partner /
Address /
PostTown /
Postcode / / Telephone /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Full Names of Children / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Former Partner of :(state name) /
Name of Former Partner /
Address /
PostTown /
Postcode / / Telephone /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Full Names of Children / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Ex-partner Check(s) sent: (1) ………………Inits: …………(2) ..………………Inits: …………Cont.
Former Partner of :(state name) / Name of Former Partner /
Address /
PostTown /
Postcode / / Telephone /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Full Names of Children / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Former Partner of :(state name) /
Name of Former Partner /
Address /
PostTown /
Postcode / / Telephone /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Full Names of Children / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Former Partner of :(state name) /
Name of Former Partner /
Address /
PostTown /
Postcode / / Telephone /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Full Names of Children / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
(3) ………………Inits: …………(4) ..………………Inits: …………(5) ………………Inits: …………
If you have children of pre-school age please supply the name of your Health Visitor and the practice where based.Name of Health Visitor /
Practice /
Health Visitor Check(s) sent:………………Inits:………………
If you have children of Infant/Junior school age, please supply the name of the school, the Head Teacher and the name(s) and date(s) of birth of the child(ren) attending the school.Name of Infant/Junior School /
Name of Head Teacher /
School Address /
PostTown /
Postcode / / Telephone /
Child(ren) attending School / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Primary School Check(s) sent:………………Inits:………………
If you have children of Secondary school age, please supply the name of the school, the Head Teacher and the name(s) and date(s) of birth of the child(ren) attending the school.Name of Secondary School /
Name of Head Teacher /
School Address /
PostTown /
Postcode / / Telephone /
Child(ren) attending School / / D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
/ D.o.B. / //
Secondary School Check(s) sent:………………Inits:………………
If you have previously worked with children in any capacity whatsoever, paid or voluntary (e.g. school meals supervisor, childminder, scout or guide leader, etc., etc.), please supply the name of the organisation or company, the address or location, the approximate start and end dates of that work and, if your name has changed, the name you were using at that time.Name of Applicant /
Name of Organisation/Company /
Address or location /
Paid or voluntary? (please tick) / Paid / / Voluntary /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Name of Applicant /
Name of Organisation/Company /
Address or location /
Paid or voluntary? (please tick) / Paid / / Voluntary /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Name of Applicant /
Name of Organisation/Company /
Address or location /
Paid or voluntary? (please tick) / Paid / / Voluntary /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Check(s) sent:………………Inits:………………
Please use the continuation sheet on page 10 if necessary
We also need to make checks with all other Local Authorities in which you have resided since the age of 18. Please supply your previous addresses, including postcodes, the name of the Local Authority for each address, the approximate dates that you lived at each address and, if your name has changed, the name you were using at that time.NB. You may need some or all of this information for your online CRB disclosure application, so you should make a copy for this purpose.
Name of Local Authority /
Name of Applicant /
Previous Address /
PostTown /
Postcode /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Name of Local Authority /
Name of Applicant /
Previous Address /
PostTown /
Postcode /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Name of Local Authority /
Name of Applicant /
Previous Address /
PostTown /
Postcode /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Continued…
Name of Local Authority /
Name of Applicant /
Previous Address /
PostTown /
Postcode /
Date from (mm/yyyy) / / / Date to (mm/yyyy) / /
Name used at the time /
Check(s) sent:………………Inits:………………
Please use the continuation sheet on page 10 if necessary
Please supply here the details of any military service you have undergone or the information for any other checks you have been specifically asked to provide.
Please use the continuation sheet on page 10 if necessary
Document owner: / Peter Ronan / Version number: / 6INET number: / INET171539 / 1 / Date created/revised: / Jun 2014
CH(F)24(K)CH(F)24
Continuation sheet
Date form completed (dd/mm/yyyy) / //
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