Application to act as chaperone – WordPress on Azure

The Licensing Authority shall not approve a Chaperone unless it is satisfied that the person is suitable and competent to exercise proper care and control of a child. Regulation 15(4)(a) The Children (Performances and Activities) (England) Regulations 2014 (opens in new tab).

All information given on this application form will be treated in confidence, other than information relating to criminal offences. Approval is issued for one year only.

If you have change of address during the period of your licence you must notify the Local Authority.

Your details

Title

First name(Required)

Last name(Required)

Previous names (if any)

Place of birth(Required)

Date of birth(Required)

Day

Month

Year

Your details

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Have lived at the above address for 5 or more years?(Required)

Yes

If you have lived at the above address for less than 5 years, please list all previous addresses during that period(Required)

Telephone(Required)

Email(Required)

Current/most recent employer

Name of current/most recent employer

Position held

Start of employment

Day

Month

Year

End of employment (if applicable)

Day

Month

Year

Reasons for applying to become a chaperone

Please add any other relevant work experience e.g. teaching, social work, youth work, play groups, voluntary work

Licence approval to start from

Day

Month

Year

Additional information

Please list any relevant qualifications you currently hold

e.g. safeguarding

Have you previously been approved as a chaperone?(Required)

Yes

Please give the name of approving Authority(Required)

Please give the licence reference number(Required)

Have you completed safeguarding training?(Required)

Yes

Please provide certificate details(Required)

If you have not recently completed safeguarding training, you must complete the NSPCC ‘Protecting Children in Entertainment’ online course (opens in new tab).

Are you a registered child minder or foster carer?(Required)

Yes

Please give the name of approving Authority(Required)

Do you have a current & valid DBS?(Required)

Yes

DBS certificate number(Required)

Are you on subscribed to the update service?(Required)

Yes

Additional information

Do you have a current first aid qualification?(Required)

Yes

Do you have a valid driving licence?(Required)

Yes

Does your car insurance allow you to carry passengers whilst you are employed as a chaperone?(Required)

Yes

Additional information

Are you registered disabled?(Required)

Yes

Please provide registration number(Required)

Do you have any health condition that might have a bearing on your application?(Required)

Yes

Please provide details. Please note any changes in medical condition should be notified to the local authority immediately. Failure to do so may invalidate your licence.(Required)

Reference details

Please give the name, address, email address and telephone number of two responsible persons who would be prepared to give you references as to your suitability to be a chaperone. At least one of these should know you in a professional capacity; please state in which capacity your references are known to you.

Reference - person 1 (professional)

First name(Required)

Last name(Required)

Job title(Required)

Reference - person 1 (professional)

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Email(Required)

Telephone(Required)

Relationship(Required)

Reference - person 2

First name(Required)

Last name(Required)

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Reference - person 2

Email(Required)

Telephone(Required)

Relationship(Required)

Are you applying for a voluntary or professional licence?(Required)

voluntary

professional

Declaration

if there are any changes to your application before renewal or if you have a change of address during the period of your licence please notify the Local Authority.

Do you have any criminal convictions?(Required)

Yes

Please provide details(Required)

Have you been convicted of an offence during the past year?(Required)

Please note: any convictions/criminal charge should be notified to the local authority immediately. Failure to do so may invalidate your licence.

Yes

Please provide details(Required)

Declaration(Required)

I hereby declare that the above information is true, to the best of my knowledge. I understand I would be liable to prosecution if I wilfully stated anything, which I knew to be false, or did not believe to be true.

Upload passport-sized photograph

Please upload one passport-sized photograph(Required)

Max. file size: 50 MB.

Summary

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