Home address:
Postcode:
Mobile number:
Date of Birth:
For Dinghy and Senior Dinghy Instructors, please provide your RYA reference number, found on your Instructor certificate:
Which qualifications do you hold?
Assistant Instructor, expires:
Dinghy Instructor, expires:
Racing Endorcement, date of issue:
Senior Instructor, expires:
First Aid, expires:
Power Boat Level 2, date of issue:
Safety Boat, date of issue:
Other:
Please complete the self declaration form as part of our safeguarding policy
Name: Gender: MaleFemale Do you have any convictions, cautions, reprimands or final warnings that are not protected as defined by the Rehabilitation of offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)? YesNo
If Yes please give details:
Have you ever been known to any Children’s Services department or Police as being a risk or potential risk to children? YesNo
If Yes please give details:
Have you been the subject of any disciplinary investigation and/or sanction by any organisation due to concerns about your behaviour towards children? YesNo
If Yes please give details:
Confirmation of Declaration (tick box below) I declare that to the best of my knowledge the information given above is correct and understand that any misleading statements or deliberate omission may be sufficient grounds for disciplinary action and/or the withdrawal of my appointment.
I understand that I may be asked to provide a Criminal Records Disclosure and consent to do so if required. I agree to inform the organisation within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children or young people.
I understand that the information contained in this form and in the Disclosure, or relating to subsequent concerns about my behaviour, may be shared with regulatory bodies and/or other persons or organisations, in circumstances where this is considered necessary to safeguard children.
Electronic Signature
Print name:
Counter signature of parent / guardian if Instructor / Assistant Instructor is under 18: Print name: Date:
Relevant Medical Conditions Do you have any relevant medical conditions to the activity of coastal dinghy sailing that the instructors and volunteers ought to be made aware of? YesNo
Emergency Contact Details Please provide the details of one contact who will be within a 20 minute drive of the Sailing Club at all times.
Name of Contact Parent/Carer/Relative or Friend Emergency Contact Number GDPR We seek your consent to hold all the information in this form for the duration of Sail Training this year. YesNo
For those travelling abroad before sail training please follow Government guidance on self-isolation on return to England unless the country is covered by the travel corridor exemption. Countries and territories can be taken off or added to this list at any time so please stay up to date with current travel corridors