Personal Disclosure and DBS/CRB Checklist Form

PERSONAL DISCLOSURE AND DBS/CRB CHECKLIST FORM

(To be completed by all Coaches, Officials, Staff & Volunteers)

You have a right of access to information held on you and other rights under the Data Protection Act 1998

PART A

Title First Name Last Name Any names by which you may have been known previously
Address /

 

 

Post Code

Date of Birth Sex

Male / Female*

Membership No.

*Please delete as appropriate

 

Coach Level (if applicable)
Referee Level (if applicable)
Position held within Squash Wales (if applicable)

 

Current Club(s) Position Start Date

CONFIRMATION OF IDENTITY (must be completed by a designated Club official)

I confirm that I have seen the following identification documents e.g. passport, driving licence, relating to this person: 1st Document ……………………………………………………………………………………………………. No: ……….……………………………………..
2nd Document …………………………………………………………………………………………………… No: ………..……………………………………..

Signature of club secretary or other designated officer

……………………………………………………………………………………………………………………………………………………………………….

Print Name ……………………………………………………………………………………………………………………………………………………………………..

Date ………………………………………………………………………………………………………………………………………………………………………………….

Club Details/Position ……………………………………………………………………………………………………………………………………………………

PART B – SELF DECLARATION

Have you ever been convicted of or cautioned for any Criminal offences including driving offences (see Note below)?
YES/NO*

If YES, please supply details. (Please use a separate sheet if necessary)

………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………..

NOTE: You are advised under the provisions of the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975 as amended by the Rehabilitations of Offenders Act 1974 (exceptions amendment) Order 1986 that you should declare ALL convictions including spent convictions.

Are you a person known to any social services department as being an actual or potential risk to children or vulnerable adults?
YES/NO*

If YES please supply details (Please use a separate sheet if necessary)

………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………….

Have you had a Squash Wales (or any other) disciplinary sanction relating to the abuse of children or vulnerable adults?
YES/NO*

If YES, please supply details. (Please use a separate sheet if necessary)

…………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………

Have you had a Squash Wales (or any other) disciplinary sanction relating to any matter? YES/NO* If YES, please supply details. (Please use a separate sheet if necessary)
………………………………………………………………………………………………………………………………………………………………………

*Delete as appropriate

IMPORTANT
I hereby consent to Squash Wales undertaking police and/or social services checks against me.

I undertake to inform Squash Wales immediately upon arrest and/or being charged with/cautioned for any criminal offence.

I understand that the information contained on this form, the results of police and social services checks and information supplied by third parties may be notified to my club/organisation and may be supplied by Squash Wales to other persons or organisations that have an interest in safeguarding and protecting children and/or vulnerable adults.

Signed by the above named individual

…………………………………………………………………………………………………………….. Date ……….…………………………………

ENHANCED DBS/CRB CHECKLIST

Date of your enhanced DBS/CRB disclosure obtained via Squash Wales

…………………………………………………………………………………………………………………………………………….. ………………………….

The Squash Wales Safeguarding & Protecting Children Policy states that all Coaches must have an enhanced DBS/CRB disclosure which was obtained via an application made directly through Squash Wales and which should be updated every 3 years. PLEASE NOTE that if you have an enhanced DBS/CRB disclosure that was issued by another organisation this does NOT meet the Squash Wales criteria in the Safeguarding & Protecting Children Policy and Procedures.

If you do not have an enhanced DBS/CRB disclosure, or you have one that was not issued as a result of an application made directly through Squash Wales, we will send you an application form with full details of how to complete and return it.

If you have any queries or require any further information please contact the Squash Wales office.

PART C – PERSONAL DISCLOSURE DISCLAIMER

To be completed only by Referees who are involved with Senior League Match refereeing duties only. I undertake not to have ANY involvement with Junior activities within Squash Wales.

Signed ………………………………………………………………………………………………………………………………………………………………..

Print Name ……………………………………………………………………………………………………………………………………………………………………..

Date …………………………………………………………………………………………………………………………………………………………………………………

When completed this form should be returned to: the Safeguarding & Protecting Children Lead Officer, Squash Wales, Sport Wales National Centre, Sophia Gardens, Cardiff, CF11 9SW

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