CHAPERONE APPLICATION FORM

CHILDREN AND YOUNG PERSONS ACT 1963

THE CHILDREN (PERFORMANCES AND ACTIVITIES) (ENGLAND) REGULATIONS 2014

The Licensing Authority shall not approve a chaperone unless they are satisfied that the person is
suitable and competent (Regulation 15 (4), The Children (Performances and Activities) (England)
Regulations 2014)

All information given in this application form will be treated in confidence. Please
complete this form in type or block capitals.

Mr / Mrs / Miss / Ms / other * *delete as appropriate

First Name(s):

Surname:

Previous
Surname(s)

Date of Birth: National Insurance No:

Nationality:

Current Dates FROM: MM/YYYY TO: MM/YYYY

Address:
Address:____________________________________________________________
___________________________________________________________________
___________________________________________________________________
_____________________________Postcode:_____________________________

Other You must provide all other addresses where you have lived in the last 5 years. There must be no gaps in dates,
however, overlapping dates are acceptable. USE A CONTINUATION SHEET IF NECESSARY.
Addresses:
FROM MM/YYYY TO MM/YYYY

Address:____________________________________________________________
___________________________________________________________________
_____________________________Postcode:_____________________________

FROM MM/YYYY TO MM/YYYY

Address:____________________________________________________________

__________________________________________________________________

________________________________Postcode:__________________________

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Name and Address of Present
Employer:

Type of Work:

Professional Qualifications

Are you registered as a Child Minder or Foster Carer? *delete as appropriate *YES/NO

If YES to either of these, please give the name and address of approving Authority:

Do you have a current First Aid qualification? *YES/NO

Do you have a valid Driving Licence *YES/NO

Does your car insurance allow you to carry passengers whilst you are employed as a *YES/NO
Chaperone?

Do you have any health conditions that might have a bearing on your application? *YES/NO
If YES, please give details
Please give details, on a separate sheet, of any other relevant work experience (e.g. teaching,
social work, youth work, child minding, playgroups, nursery nurse, or if you have acted in a voluntary capacity
such as Cubs/Brownies). Please also add anything else that you would wish to add in support of this
application.

Have you ever been approved as a chaperone? *Yes/No

When approved, your name will appear on a list of the Local Authority approved Chaperones,
unless you indicate otherwise; do you agree to your name being placed on the list? *Yes/No

Name of Theatre/Dance School/Organisation

you currently are connected to/working for:

Please provide the following:

Name, address and telephone number of two people who have known you for a minimum of
two years and who would be prepared to give you a reference as to your suitability to be a
Chaperone.

At least one of the people named should be your present or previous employer (within the last
two years). If unemployed during this period, one should know you in a professional capacity;
please state what capacity the person is known to you.
DO NOT USE FAMILY MEMBERS AS REFEREES
Name: Name:

Position: Position:

Address: Address:

Telephone/Mobile: Telephone/Mobile:

Email: Email:

Professional/Personal (delete as appropriate) Professional/Personal (delete as appropriate)

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 Declaration to be signed by the Applicant

I hereby declare that the above information is true, to the best of my knowledge. I
understand that I would be liable for prosecution or the licence be revoked if I wilfully
stated in it anything which I knew to be false or did not believe to be true.

Signed: Date:

Contact Telephone Number:

(for enquires about application only)

Please return your completed application form together with one passport size
photograph to:
School Attendance & CME Team
RIVERSIDE HOUSE
MAIN STREET
ROTHERHAM
S60 1AE

Telephone: 01709 822528 Email: childemployment@rotherham.gov.uk

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