Histon and Impington Council of Churches
Holiday Club 2017 Leader registration

First Name*

Surname*
E-mail Address*
Telephone number*
Church to which you are affiliated 


Do you have a Current (under 3 years old) First Aid Certificate?  

Have you helped with this Holiday Club in the last 2 years? 


Your preferred age group 

Your preferred activity 

We insist on current full clean DBS checks for all leaders and helpers over the age of 16.
    If you do not have one have one  may we apply for one?
    If you do have one, please given the following information:

Disclosure Number
Date of issue 
This will need to be seen by one of the core team: Tim Blake, Gill Gay or Eileen Milner

Declarations re. Child protection issues (we have to do this by law). Confidential 
As a committee we realise this is a sensitive issue but we are required to follow the guidelines from the Home Office following the Children Act 1989 which advises that all voluntary organizations, including churches, take steps to safeguard the children who are in their care. We therefore ask you to make the following declarations: (If the answer is YES to any of the following please discuss with your church leader.)
Because of the nature of the work for which you are applying, this position is exempt from the provision of section 4(ii) 01 the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, and you are therefore not entitled to withhold information about convictions which, for other purposes are "spent' ' under the provisions of the Act. In the event of an appointment, any failure to disclose such convictions could result m the withdrawal of approval to work with children in the church.

Do you have any current or spent criminal convictions, cautions, bindovers or cases pending? 

Have you ever been held liable by a court under the Rehabilitation of Offenders Act 1974 for a civil wrong, or had an order made against you by a matrimonial or a family court? 

Has your conduct ever caused, or been likely to cause harm to a child or put a child at risk, or, to your knowledge, has it ever been alleged that your conduct has resulted in any of these things?

Can we keep your details on a computer for Holiday Club administration only?  

Crèche needs (under 5)

Please state the names, ages and days on which you wish your child/ren to make use of the crèche:

If under 18

Age 

First Name of Parent/Guardian


Surname of Parent/Guardian

Emergency Contact Numbers

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