CHESHIRE CLUBS CRICKET COMMITTEE
SELF DECLARATION FORM FOR CLUB MEMBERS
This page contains a form for the use of members of Clubs which are affiliated to the ECB through the CCB. All such members which come into contact with young players through their membership should fill in a copy of this form and give it to their Club Welfare Officer to be kept in a secure place.
........................................ Cricket Club
Self Declaration Form
STRICTLY PRIVATE AND CONFIDENTIAL
PERSONAL DETAILS
| Surname: | First Names: | |||||||||
| Address: | Email: | |||||||||
| Home Telephone | ||||||||||
| Mobile: | ||||||||||
| Work Telephone* | ||||||||||
| Postcode: | ||||||||||
| Date of Birth: | * If necessary may wecontact you at work? | Yes / No | ||||||||
| Previous Clubs: | 1. | 3. | ||||||||
| 2. | 4. | |||||||||
The England and Wales Cricket Board (ECB) and affiliated cricketing organisations, including this Cricket Club, aim to promote equality of opportunity for all persons and welcome participation from a wide range of individuals, including those with prior criminal records. The voluntary position for which you have applied is an exempted occupation for the purposes of the Rehabilitation of Offenders Act 1974 (as amended by the Rehabilitation of Offenders Act 1975). All ‘spent’ and ‘unspent’ convictions must be declared. Having an ‘unspent’ conviction will not necessarily impede your involvement with Cricket: this will depend on the circumstances and background to your offence. If you fail to disclose an offence and the ECB or any affiliated organisation is later informed of any undisclosed criminal matter, you may be subject to disciplinary action. Evaluation of information is based on strict confidentiality and discretion.
1. Have you ever been convicted of any criminal offences or accepted any reprimands or cautions or Police warnings?
Yes
No If yes, please supply details of any criminal convictions / cautions / reprimands:
2. Are you a person known to any Social Services department as being an actual or potential risk to Children or Young People?
Yes
No If yes, please supply details of incident(s) and social services department involved:
3. Have you ever had a disciplinary sanction (from any sports or other organisation’s governing body) relating to child welfare?
Yes
No If yes, please supply details of sport and the incident:
I declare that the information given herein is correct to the best of my knowledge. I understand that it is necessary for me to declare any information requested and that the voluntary position for which I have applied may involve access to Children, Young People and/or Vulnerable Adults. I hereby give my consent for the ECB to conduct a Criminal Records Bureau (CRB) check if so required. The ECB Ethics and Compliance Manager may be informed of disclosed information. I agree to notify the club of any pending prosecutions / cautions / warnings / reprimands or convictions whilst I remain in post.
Full Name: Signature: Date:
Please return this form to the Club Welfare Officer in an envelope marked ‘Private and Confidential – SDF’.
Please tick the box if you have used additional sheets of paper to provide further information :
12.03.06
To print off a copy of this form follow the first hyperlink below. Otherwise you may return to the Home Page.