APPLICATION FOR APPROVAL OF A CHAPERONE

“The Licensing Authority shall not approve a chaperone unless they are satisfied that she (he) 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, other than information relating to criminal offences. Please complete this form in type or block capitals. 

Title	MR / MRS / MISS / MS / OTHER (delete as appropriate)	
First Names		
Surname		
Date of Birth		
Address, inc. postcode	
	
How long have you lived at this address?		
If less than 5 years please list previous address(es)

	
Telephone No		
Email Address		

a) Have you ever been refused registration as a chaperone by another Local Authority?	Yes / No	
If so please give further details and confirm dates	

	
b) Do you consent for Solihull MBC to share your information under GDPR regulations with other organisations/ local authorities who may require information about your application and/or registration?
	Yes / No	
If you answer no to either of these questions, please be aware we might not be able to proceed with your application	

Please give details of any relevant work experience e.g., teaching, social work, youth work, child minding, nanny, play groups, nursery nurse, or if you have acted in a voluntary capacity such as Clubs/Brownies. 
Please also add anything else that you would wish to add in support of this application. You may continue on another sheet if required.	

	

References 

Please provide details of two responsible persons who will be prepared to give you references as to your suitability to be a chaperone. References should be from separate sources and not from the same organisation or employer. At least one of these should know you in a professional capacity. Please state in what capacity the person is known to you. You must have known them for at least two years and they must not be from a spouse, partner or family relation or from someone with whom you live.

Reference 1 – Current/ last employer	
Referee name		
Company Name		
Company address		
Position held		Type of work		
Date started		Date ended (if applicable)		
Email:		Tel no.		

Reference 2:	
Name:		
Address:		
Email:		Tel no.		
Capacity known to you		
How long have you known the referee?		

Criminal Offences

Due to the nature of the work, we need to know if you have ever been convicted of a criminal offence, (including any traffic offences) or had an allegation made against you or been the subject of a child protection case conference. Please tick the appropriate box and provide relevant details.

I have not been convicted of any offences.		I have not had an allegation made against me or been the subject of a child protection case conference.		
I have been convicted of the offences shown below.		I have had an allegation made against me/been the subject of a child protection case conference as noted below. 		

Date	Court/ Authority	Offence/ Allegation	Outcome	

DECLARATION AND CONSENT TO SHARE INFORMATION

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

I give permission to disclose my name as a registered chaperone to other local authorities, schools, production companies and parents when we send a copy of a child performance licence.

If I move to another Borough I will notify Solihull MBC immediately and return the chaperone licence. I am aware that my licence will no longer be valid and I will need to apply to the new local authority.

I give my consent for the Education Inclusion team to contact relevant agencies to validate the information on this application.	
Applicant Signature		
Date		

You can email your application to: inclusion@solihull.gov.uk

Or by post to: Education Inclusion Service
                         Solihull MBC
                         Manor Square 
                         Solihull
                         B91 3QB

Or by hand to: Solihull Connect Centres 

Further information can be found on our webpage:
https://www.solihull.gov.uk/Business/Child-employment-and-performance

The Education Inclusion Service can be contacted by:
Email: inclusion@solihull.gov.uk
Tel:  0121 704 6663

CHILDREN AND YOUNG PERSONS ACT 1963
CHILDREN (PERFORMANCE) REGULATIONS 1968
CHILDREN (PROTECTION AT WORK) REGULATIONS 1998
CHILDREN (PERFORMANCES) (MISCELLANEOUS AMENDMENTS) REGULATIONS 1998
The Children (Performances and Activities) (England) Regulations 2014 (legislation.gov.uk)