Name (Mr/Mrs/Ms)

GAISCE – THE PRESIDENT’S AWARD LEADER COMMITMENT FORM

Please print off this form as a hard copy is required, fill in the requested details and sign.

The form should then be returned to Gaisce – The President’s Award.

Name (Mr/Mrs/Ms):______

Any other name previously known as: ______

Home Address:______

E-mail address:______

Tel nos: ______

Date of Birth:___/___/___ Place of Birth: ______

Do you suffer from any illness/disability/medical condition, which may at times affect your ability to work with young people? Yes No If yes, please give details:

______

______

Please supply the name, address, telephone numbers etc and position of two people (non relative), who know you well and can provide us with a reference. One of the referees, where relevant, should be your immediate supervisor. Gaisce - the President’s Award will make contact with both of your nominated referees:

(1)______(2) ______

______

______

Referee’s Tel No: ______Referee’s Tel No: ______

Mobile no: ______Mobile no: ______

E-mail address: ______E-mail address: ______

Position: ______Position: ______

Declaration (confidential)

Have you ever been convicted of a Criminal Offence or been the subject of a Caution or of a Bound

Over Order: Yes No

Signed: ______

If yes, please state below the nature and date(s) of the offence(s):

Nature of OffenceDate of Offence

______

______

I confirm that nothing within my personal or professional background deems me unsuitable for a post, which involves working with children.

I declare that the above information is true.

I promise to uphold the standards of the Award and to do everything in my power to ensure that each young person achieving an Award under my guidance will have earned that Award.

I have read and agree to implement Gaisce’s Child Protection Policy. I will take all reasonable steps to draw the guidelines to the attention of other adults that I involve in the programme.

Signed: ______Date: ______

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Have you attended a PAL Training Workshop? If so, please give details below:

Venue: ______Date of Workshop: ________

If not, it is now a requirement that all new PALs must attend a one-day PAL Training Workshop

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Details of where you will operate the Award:

Operating Body (School, club etc. where Gaisce is being undertaken) is______

Address of Operating Body for correspondence: ______

______

E-mail address: ______

Signed: ______Date:______

This application will only be accepted pending a positive outcome from the Garda vetting process and refereeing by Gaisce – The President’s Award.

Gaisce - The President’s Award

Ratra House, North Road, Phoenix Park, Dublin 8.

Tel: 00 353 (0)1 6171999 Fax: 00 353 (0)1 6707060

Website: E-mail:

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