Isle of Wight Council

	APPLICATION FOR MATRON LICENCE CONFIDENTIAL
	This form should be completed by any person wishing to act as Matron to children who take part in performances under Section 37 of the Children and Young Persons Act 1963.

	Isle of Wight Council operates a procedure which protects the position of children taking part in performances.
	The position for which you are applying, with the privileged and substantial access it gives to children as per the conditions set out in Home Office circular 47/93, is an exempted occupation under the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. This means that you do not have the right not to reveal spent convictions. Spent convictions must, therefore, be disclosed.
	This form should take 7 days to process from receipt of application.
	Please click the NEXT button below to continue to fill in this form.

	Application to the Isle of Wight Council for approval to act as Matron to children who take part in performances under Section 37 of the Children and Young Persons Act 1963.
	You are required to indicate whether you have convictions and/or cautions, reprimands or warnings as follows:

*

Have you been convicted at a Court or Cautioned by the Police for any offence?

Yes No

If YES, please provide details below of the conviction/s or caution/s or reprimands or warnings, including offence/s, date/s, Court or Police who dealt with the matter.

Please enclose proof of Criminal Records Bureau Check (CRB)

Applicants Details

TO ASSIST IN THIS PROCESS, PLEASE PROVIDE THE FOLLOWING ADDITIONAL INFORMATION:

	Title
*	Forename
	Middle name/Initials
*	Surname

Maiden Name

Previous Married Name or Other Names

	Date of Birth
	Place of Birth

Applicants Address

*	Building/house name/number
*	Street address
*	Town Name
	County
*	Postcode
	Tel Number (include area code)
	Email address
	Fax

	Previous Addresses (during last five years)
	Last Address Occupied

	Building/house name/number
	Street address
	Town Name
	County
	Postcode
	Fax

	Date From
	Date To

Previous address (to address given on page prior to this)

	Building/house name/number
	Street address
	Town Name
	County
	Postcode

	Date From
	Date To

Any other Addresses in the last five years (please include County and Postcode)

Dates from and to (Year and Month)

Experience in Care, Control and Supervision of Children

Brief Details of Present and Previous Employment

Dates from and to (Year and Month)

Referees

NAME AND ADDRESS OF TWO REFEREES (NOT IMMEDIATE FAMILY) WHO HAVE KNOWLEDGE OF YOUR EXPERIENCE AND SUITABILITY TO UNDERTAKE FULL RESPONSIBILITY FOR CHILDREN. STATE THE CONTEXT IN WHICH YOU ARE KNOWN TO THEM

Referee 1

	Title
*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town Name
	County
*	Postcode
	Tel Number (include area code)
	Email address
	Fax

Referee 2

	Title
*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town Name
	County
*	Postcode
	Tel Number (include area code)
	Email address
	Fax

	Declaration
	Please print off this form and fill this section in by hand before returning your form to the address below.

I have made an application as a Matron under the Children (Performance) Regulations. I understand that this work is subject to a police record check and I am aware that spent convictions will be disclosed. I have read and understood the guide for Matrons and Home Office Guide extract. I enclose my certificate to say that I have been Police checked.

*

Signature

Signed ............................................................................... Name................................................................................. Date...................................................................................

THIS FORM SHOULD BE RETURNED, MARKED CONFIDENTIAL, TO: Education Welfare Service, Thompson House, Sandy Lane, Newport, Isle of Wight PO30 3NA Telephone: (01983) 533523

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013