Chairman	Dan Brown	106 Beechwood, Yeovil, Somerset, BA20 2NF
Vice Chairman	Roger Willoughby	Tess Cottages, Sandhills, Holwell, Dorset, DT9 5LE
Secretary	Andy Rossall	25 Marsh Lane, Yeovil, Somerset BA21 3BX

Personal Declaration Form - 2010

CONFIDENTIAL

Full Name:

Sutton Bingham and District Canoe Club is committed to child protection. The club has adopted the British Canoe Union's "Duty of Care – Child Protection Policy and Procedures and Coaches Code of Ethics".
As we are a family club where adults and children attend many of the available activities together, all adult members of the club are required to complete this Personal Declaration Form.

Previous Surnames (if Applicable):

Address:

Post Code:

Date of Moving to this Address

Telephone Number

Date of Birth:

BCU Membership Number (if applicable):

I understand the nature of my role and responsibilities at Sutton Bingham and District Canoe Club. I confirm that I have read and understand the club’s code of conduct, that I am committed to the child protection policy of this organisation and that I accept my responsibility to care for the children and young people with whom I come into contact. (The above mentioned documents are outlined on the back of this form and can be viewed on the club web site www.sbd.cc or copies are available from the club’s Child Protection Officers).

I can confirm there is no reason why I should not have unsupervised access to children or young people whilst participating in activities organized by Sutton Bingham and District Canoe Club. I hereby consent to agents of the BCU undertaking CRB, police and/or social service checks against me. I understand that the information contained on this form, or the results of checks with the above may be notified to Sutton Bingham and District Canoe Club.

Self Declaration

Have you ever been convicted of a criminal offence or been the subject of a Caution or a Bound Over order? YES / NO
Are you a person known to any social services department as being actual or potential risk to children or have you had a disciplinary sanction from a sports or other organization’s governing body relating to child abuse? YES / NO

If YES to either of the above please give details: (continue on back page if necessary)

……………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………

Note: You are advised that under the Rehabilitation of Offenders Act 1974 (exceptions) order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions Amendment) Order 1986 you should declare all convictions including “spent” convictions.

Signed by the above named individual: Dated:

………………………………………………. ……………………………………….

Please return this form marked CONFIDENTIAL direct to: The Child Protection Officer, Sutton Bingham & District Canoe Club