Forms home Application to act as chaperone The Licensing Authority shall not approve a Chaperone unless it is satisfied that the person is suitable and competent to exercise proper care and control of a child. Regulation 15(4)(a) The Children (Performances and Activities) (England) Regulations 2014 (opens in new tab). All information given on this application form will be treated in confidence, other than information relating to criminal offences. Approval is issued for one year only. If you have change of address during the period of your licence you must notify the Local Authority. Personal detailsHiddenPersonal detailsTitlePlease selectMrMrsMrsMsMissDrFirst name(Required) Surname name(Required) Previous names (if any) Place of birth(Required) Date of birth(Required) Day Month Year Address(Required) Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Have lived at the above address for 5 or more years?(Required) Yes No If you have lived at the above address for less than 5 years, please list all previous addresses during that period(Required)Telephone(Required) Email(Required) Current/most recent employerHiddenCurrent/most recent employerName of current/most recent employer Position held Start of employment Day Month Year End of employment (if applicable) Day Month Year Reasons for applying to become a chaperoneHiddenReasons for applying to become a chaperonePlease add any other relevant work experience e.g. teaching, social work, youth work, play groups, voluntary workLicence approval to start from Day Month Year Additional informationHiddenAdditional informationPlease list any relevant qualifications you currently holde.g. safeguarding Add RemoveHave you previously been approved as a chaperone?(Required) Yes No Please give the name of approving Authority(Required) Please give the licence reference number(Required) Have you completed safeguarding training?(Required) Yes No Please provide certificate details(Required) If you have not recently completed safeguarding training, you must complete the NSPCC ‘Protecting Children in Entertainment’ online course (opens in new tab).Are you a registered child minder or foster carer?(Required) Yes No Please give the name of approving Authority(Required) Do you have a current & valid DBS?(Required) Yes No DBS certificate number(Required) Are you on subscribed to the update service?(Required) Yes No Do you have a current first aid qualification?(Required) Yes No Do you have a valid driving licence?(Required) Yes No Additional informationDoes your car insurance allow you to carry passengers whilst you are employed as a chaperone?(Required) Yes No Are you registered disabled?(Required) Yes No Please provide registration number(Required) Do you have any health condition that might have a bearing on your application?(Required) Yes No Please provide details. Please note any changes in medical condition should be notified to the local authority immediately. Failure to do so may invalidate your licence.(Required) Reference details Please give the name, address, email address and telephone number of two responsible persons who would be prepared to give you references as to your suitability to be a chaperone. At least one of these should know you in a professional capacity; please state in which capacity your references are known to you. Reference - person 1 (professional)Name(Required) Job title(Required) Address(Required) Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Email(Required) Telephone(Required) Relationship(Required) Reference - person 2Name(Required) Address(Required) Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Email(Required) Telephone(Required) Relationship(Required) Chaperoning detailsHiddenChaperoning detailsAre you applying for a voluntary or professional licence?(Required) voluntary professional DeclarationHiddenDeclaration if there are any changes to your application before renewal or if you have a change of address during the period of your licence please notify the Local Authority. Do you have any criminal convictions?(Required) Yes No Please provide details(Required)Have you been convicted of an offence during the past year?(Required)Please note: any convictions/criminal charge should be notified to the local authority immediately. Failure to do so may invalidate your licence. Yes No Please provide details(Required)Declaration(Required) I hereby declare that the above information is true, to the best of my knowledge. I understand I would be liable to prosecution if I wilfully stated anything, which I knew to be false, or did not believe to be true. Upload passport-sized photographHiddenUpload passport-sized photographPlease upload one passport-sized photograph(Required)Max. file size: 10 MB. Summary {all_fields}
