Governor Appointment Declaration Form

School at which you wish to become a Governor: / Torpoint Community College

A. Declaration

Title
Surname
Forenames
Date of Birth
Address
Post Code
Tel. Home
Tel. Work
E-mail

PEOPLE WHO ARE INELIGIBLE TO BE A GOVERNOR:

You are unable to be appointed as a governor if you:

·  are under 18 years of age;

·  are already a governor of the school (i.e., you are not trying to hold two governor positions but you may change category, or be reappointed);

·  detained under the Mental Health Act 1983;

·  are a bankrupt or subject to a disqualification order under the Company Directors Disqualification Act 1986 or to an order made under section 429(2)(b) of the Insolvency Act 1986;

·  have been removed from a charity trusteeship by the Charity Commissioners or High Court on the grounds of misconduct or mismanagement;

·  are included in the list of teachers or workers prohibited or restricted from working with children or young persons (currently named List 99);

·  have been disqualified from being a proprietor, teacher or employee in any independent school by an Independent Schools Tribunal or the Secretary of State;

·  have in the previous five years (or since becoming a governor) been sentenced to three months or more in prison (whether this was suspended or not) without the option of a fine before becoming a governor or since being a governor;

·  have in the previous twenty years, received a prison sentence for two and a half years or more;

·  have at any time received a prison sentence for five years or more;

·  have been fined for causing a nuisance or disturbance on school premises during the five years prior to, or since, appointment or election as a governor;

·  have been subject to a disqualification order under the Criminal Justice and Court Services Act 2000;

·  have refused to an application being made to the Criminal Records Bureau for a criminal records certificate;

·  act as the clerk to the governing body of the school at which you wish to become a governor.

Please note that all governors have to undergo an enhanced Disclosure and Barring Service (DBS) check. This check will also take place each time an existing governor seeks re-appointment. A refusal to undergo this check will result in a non-appointment.

Please also note that your details will be placed on our computer database. Your data will be used in accordance with the principles set out in the Data Protection Act (DPA) 1998. This data will only be used for internal LA purposes including sharing with members, governing bodies and for mailing information to you as and when required.

By signing below you are confirming that the above details are correct, that none of the reasons for disqualification apply and that this information may be used in accordance with the DPA.

Signature
Date

B. Governors' Ethnic Background Record Form.

Please tick one box only to indicate your ethnic background.

White: / Mixed
Cornish / White and Black Caribbean
Other White British / White and Black African
Irish / White and Asian
Traveller of Irish Heritage / Any other mixed background
Gypsy/Roma
Asian or Asian British / Black of Black British
Indian / Caribbean
Pakistani / African
Bangladeshi / Any other Black background
Any other Asian background
PTO
Chinese / Any other ethnic background
I do not wish an ethnic background category to be recorded

Any information you provide will be used solely to compile information on the ethnicity of governors, to aid any future development of support to governors and for contacting individual governors from time to time on matters relating to school governance. This information may be passed on to officers of the Children, Schools and Families Department and the Department for Education and Skills (DfES) to contribute to local and national developments.

C. Governor Type

The person overleaf wishes to become one of the following category of governor (please tick one box only). This table is designed for all categories, other than LA Governors.

Associate member / Partnership
Community / Sponsor
Foundation / Staff (All staff)
Foundation (Ex-Officio) / Staff (Non Teaching
Foundation (Parent) / Staff (Teaching)
Parent (Appointed) / Staff (Teaching)
Parent (Elected)

Please return this form to the school at which you are seeking to be a governor, together with proof of identity. On receipt of your nomination, if successful, you will receive an email in relation to completing an enhanced DBS check, which will need to be completed prior to any work undertaken at the school.

D. Term of Office

Date of Appointment:
Date Appointment effective from:

E. For GST Use Only

Acknowledgement letter sent / Confirmation letter sent
EMS / CRB / Pack / UDF

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