Part B

Self Declaration (for completion by the individual named in Part A)

Have you ever been convicted of any criminal offences? (excluding motoring offences) YES/NO*

If YES, please supply details of any criminal convictions:

__________________________________________________________________________________________________________________________

NOTE: You are advised under the provisions of the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions Amendment) Order1986 you should declare all convictions including ‘spent’ convictions.

Are you a person who has been investigated by any Social Services department as being an actual or potential risk to children or young people? YES/NO*

If YES, please supply details:

__________________________________________________________________________________________________________________________

Have you had an F.A. disciplinary sanction relating to child abuse? YES/NO*

If YES, please supply details:

__________________________________________________________________________________________________________________________

* Delete as appropriate

IMPORTANT

I understand that The F.A. holds relevant information in accordance with data protection in relation to ChildProtection matters.

I hereby consent to The Football Association undertaking police and/or Social Services checks against me.

I understand that the information contained on this form, the results of police and Social Services checks andinformation supplied by third parties, will be included on The F.A. Child Protection List, may be notified to my club and may be supplied by The Football Association to other persons or organisations who have an interest in child protection issues.

____ Please put a cross in this box if you do not wish to receive any other Football related information

Signed by the above named individual:______________________________

Date:________________________________