Full Name *

First Name

Last Name

Date of Birth *

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DD

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you want a copy of this form sent to you? *

This will be done manually so may take a few days to be sent to you. It will be sent to the email address specified above.

YES

NO

Have you ever been convicted of any criminal offence? *

YES

NO

Have you ever been cautioned, reprimanded or given a final warning by the police or bound over to keep the peace? *

YES

NO

Has your conduct ever caused or been likely to cause significant harm to a child or young person aged 17 or under or a vulnerable adult, or put a child,young person or vulnerable adult at risk of significant harm? *

YES

NO

To your knowledge has it ever been alleged that your conduct has ever resulted in any of these things? *

YES

NO

Do you have any health problems which might affect your work with children, young people or vulnerable adults? *

YES

NO

Have you, since the age of 18 ever been known by any name other than the one declared (e.g. Maiden Name)? *

YES

NO

Have you, during the past five years had any home address other than the one declared? *

YES

NO

Have you, since the age of 16, been resident in a country other than the UK for longer than six months? *

YES

NO

AUTHORISATION TO RETAIN INFORMATION *

Please choose the correct option from the list below.

I AUTHORISE ICS to hold the information given in this form (including any sensitive information in the 'relevant details' sections), until my application is fully processed and, if my application is successful, for as long as I remain on the Short-Term Mission Chaplains list

Authorisation NOT GIVEN. If my application is successful, I understand that I will need to complete a full form each time I serve as a Short-Term Mission chaplain.

Declaration *

By dating and sending this form, I declare that the above information is true, accurate and complete to the best of my knowledge.

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