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Child Protection Committee |
THE CATHOLIC DIOCESE OF RAPHOE |
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Diocese of Raphoe Declaration
Form to be completed by Staff and Volunteers* Confidential Declaration from all staff and volunteers working with
children and young people Surname:
____________________________________________________________ Forename:
____________________________________________________________ Address:
____________________________________________________________
____________________________________________________________ Tel.:
_______________________ Mobile No.: __________________________
Email:
____________________________________________________________ Date of Birth:
_______________________ Place of Birth: ________________________ Any other name
previously known as: ________________________________________ Do you have any prosecutions pending or have you ever
been convicted of a criminal offence or been the subject of a caution or
of a bind over order? Yes _________ No
_________ If yes, please state below the nature and date(s) of
the offence(s), the court responsible for dealing with the matter, the
approximate date of the court hearing. Nature of offence:
____________________
Date of
offence: ____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________ Signed:
__________________________________ Date: __________________________ * Adapted from: Our Duty to Care: Principles of Good Practice for the Protection of
Children and Young People, Information
Pack,
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