CRONKBOURNE Cricket Club Self Declaration Form for Players

CONFIDENTIAL

If you need more space to enter your details, or you wish to give additional information, please use a separate sheet.

PERSONAL DETAILS

Surname:_________________________________________________

First Names:______________________________________________

Address:__________________________________________________________________

_________________________________________________________________________

Post Code__________________   E-mail:________________________________________

Home Telephone No:___________________ Mobile Telephone No:___________________

With discretion, may we contact you at work? _________ Work No:___________________

Please list any previous clubs and/or leagues you have volunteered/worked/played in within the last five years:-

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

4. ___________________________________________________________

5. ___________________________________________________________

The England and Wales Cricket Board Ltd (ECB), the Association of Cricket Umpires & Scorers (ACU & S) and affiliated Cricketing organizations aim to promote equality of opportunity for all persons and welcome applications from a wide range of individuals, including those with prior criminal records. The position/membership for which you have applied is an exempted occupation for the purpose 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 appointment within Cricket, this will depend on the circumstances and background to your offence. If you fail to disclose an offence and the ECB, the ACU & S or any affiliated organization is later informed of any previously 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?

YES / NO** 

If yes, please supply details of any criminal convictions______________________

__________________________________________________________________

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___________________________________________

_________________________________________________________________

3. Have you ever had disciplinary sanction (from any sports or other organization’s governing body) relating to child abuse?

YES / NO**

If yes, please supply details___________________________________________

_________________________________________________________________

I understand that it is necessary for me to declare any information requested and that the position/membership for which I have applied may involve access to Children, Young People and/or Vulnerable Adults. I hereby give my consent to the ECB for it to conduct a Criminal Record Bureau (CRB) check if so required. The ECB Welfare Cases Officer may be informed of disclosed information.

Name: ______________________________Date of Birth___________________

Signature: ________________________________ Date: ___________________

Please return to: Mark Entwisle, IOMCA Secretary, 5, Sea View Road, Onchan, IM3 4AH.           

PLEASE MARK ENVELOPE “Private & Confidential – SDF”