PLEASE COMPLETE IN BLOCK CAPITALS, AND PLACE A TICK IN COLUMNS THAT APPLY / Conference Fee
Delegate's Name / Date of Birth / Gender (circle) / Delegate / Party Leader / First Aider / Emergency Contact No. / Amount Paid / Ticket Type (circle)
1 / M / F / £ / EB / Full
2 / M / F / £
3 / M / F / £
4 / M / F / £
5 / M / F / £
6 / M / F / £
7 / M / F / £
8 / M / F / £
9 / M / F / £
10 / M / F / £
11 / M / F / £
12 / M / F / £
13 / M / F / £
14 / M / F / £
15 / M / F / £
16 / M / F / £
17 / M / F / £
18 / M / F / £
19 / M / F / £
20 / M / F / £
21 / M / F / £
22 / M / F / £
23 / M / F / £
24 / M / F / £
LEADER’S DECLARATION FORM
This form is strictly confidential and is in no way a comment or judgment on your qualities. It will be completed by all party leaders
and staff working at !Audacious. Should you have questions regarding the form please direct them to !Audacious leadership.
Full Name:Date of Birth: / Maiden or Former Names:
Home Address:
Postcode:
Telephone: / Email:
How long have you lived at the above address?
Previous Address:
Postcode:
How long have you lived at the above address?
Name of Church attended: / Name & Address of Minister:
If you are a party leader, which party are you in charge of? (Church or youth group name by which you registered?)
Please list details of previous experience of looking after or working with Children/ Young people, including details of training received.
Please circle below (if 'yes' please give details on a separate sheet of paper, please include dates, nature of conduct, whether you were disciplined, moved to other work or resigned from any paid or voluntary work as a result)
Have you ever been convicted of a criminal offence or
been cautioned by the police or bound over to keep peace? / YES / NO
Have you ever been held liable by a court for a civil wrong or had an order made against you by matrimonial or family court? / YES / NO
Has your conduct ever put a child at risk seemed likely to cause harm or actually had caused harm to a child? To your knowledge, have there ever been any allegations against you in regards to these matters? / YES / NO
If considered appropriate, do you agree to co-operate in a formal police and Dept. of Health Consultancy Check? / YES / NO
I confirm that the submitted information is correct, and that I have read, understood and will work within the structures of the Audacious Policy and Guidelines’ document.
Signed (applicant): Date:
…………………………………………………………………………………………………………………………..
Signed (Senior Leader / Church Minister):Date:
…………………………………………………………………………………………………………………………..
Notes
(1)Because of the nature of the work, this post is exempt from the provision of Section 4 (ii) of the Rehabilitation of Offenders Act 1974 (exemption Order 1975) and you are therefore not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act, any failure to disclose such convictions may result in the withdrawal of approval to work with children and / or young people at Audacious. (2) A ‘child’ for this purpose means anyone under the age of eighteen.