VCLUN1LLk]S1UDLN1 DLCLAkA1ICN

An eas|er way? Comp|ete th|s form on||ne at check.k|ds.nsw.gov.au

ersona| Deta||s:
Name:
lamlly name:
llrsL name: CLher glven name(s):
rev|ous names]a||ases:
lamlly name:
llrsL name: CLher glven name(s):
kes|dent|a| address:
Address Llne 1:
Address Llne 2:
Suburb/1own: SLaLe: osLcode:
CounLry:
Contact:
hone: Moblle:
Lmall:
uaLe of blrLh: Cender:
|ace of b|rth:
Suburb/1own: SLaLe:
CounLry:
Ident|fy|ng document:
L|cence 1ype: urlver's Llcense llrearms Llcense
Issu|ng Agency: AC1 CommonwealLh of AusLralla 1asmanla
nSW SouLh AusLralla AusLrallan 8AAl
vlC WesLern AusLralla AusLrallan Army
CLu uefence lorce Academy AusLrallan navy
n1 AnoLher counLry CLher
L|cence number:
assport 1ype: rlvaLe CovernmenL un 8efugee
Issu|ng Country:
assport number:
os|t|on deta||s:
1|t|e of ch||d-re|ated pos|t|on:
Name of organ|sat|on you are vo|unteer|ng for:
Address of th|s organ|sat|on (|f known):
I am a parent or guard|an of a part|c|pat|ng ch||d (y]n)
I am a vo|unteer or student on p|acement (y]n):
lL ls an offence for a prohlblLed person Lo apply for, aLLempL Lo obLaln, underLake or remaln ln chlld-relaLed
employmenL, or Lo slgn Lhls declaraLlon. A prohlblLed person ls a person who ls convlcLed of Lhe followlng (wheLher
ln nSW or elsewhere):
- murder of a chlld
- serlous sex offence, lncludlng carnal knowledge
- chlld-relaLed personal vlolence offence (an offence commlLLed by an adulL lnvolvlng lnLenLlonally woundlng or
causlng grlevous bodlly harm Lo a chlld)
- lndecency offences punlshable by lmprlsonmenL of 12 monLhs or more
- kldnapplng (unless Lhe offender ls or has been Lhe chlld's parenL or carer)
- offences connecLed wlLh chlld prosLlLuLlon
- possesslon, dlsLrlbuLlon or publlcaLlon of chlld pornography, or
- aLLempL, consplracy or lnclLemenL Lo commlL Lhe above offences.
A prohlblLed person lncludes a 8eglsLrable person under Lhe cbllJ ltotectloo (OffeoJets keqlsttotloo) Act 2000.
ueLalls of Lhese offences can be found onllne aL Worklng WlLh Chlldren Lmployer Culdellnes lacL sheeL 1. A
convlcLlon lncludes a flndlng LhaL Lhe charge for an offence ls proven, or LhaL a person ls gullLy of an offence, even
Lhough Lhe courL does noL proceed Lo a convlcLlon.
Dec|arat|on:
l have read and undersLood Lhe lnformaLlon above abouL prohlblLed persons. l am
aware LhaL lL ls an offence Lo make a false sLaLemenL on Lhls form.
l declare LhaL l am noL a prohlblLed person under Lhe commlssloo fot cbllJteo ooJ
oooq leople Act 1998.
l consenL Lo Lhe Commlsslon for Chlldren and ?oung eople checklng my relevanL
crlmlnal records, Lo verlfy Lhese sLaLemenLs. l undersLand LhaL Lhls lnformaLlon may be
referred Lo Lhe Commlsslon for Chlldren and ?oung eople and/or Lo nSW ollce for
law enforcemenL purposes and for monlLorlng and audlLlng compllance wlLh Lhe
procedures and sLandards for Lhe Worklng WlLh Chlldren Check ln accordance wlLh
SecLlon 36 (1)(f) of Lhe commlssloo fot cbllJteo ooJ oooq leople Act 1998.

SlgnaLure: uaLe:
Lmp|oyer to Comp|ete:
l have slghLed phoLo ldenLlflcaLlon for Lhls person

SlgnaLure: uaLe:

name: oslLlon:
Cnce you have compleLed your deLalls, you wlll need Lo slgn Lhe prlnLed form and provlde Lhe slgned
form Lo your employer/volunLeer organlsaLlon. ?ou may also wlsh Lo reLaln a copy for your records.









L|tt|e Ath|et|cs:
a safe and fr|end|y p|ace for ch||dren

Vo|unteer ] Student Dec|arat|on
lor arenLs, volunLeers, Coaches & Cfflclals

8evlsed !une 2010


DLIINI1ICNS
Ch||d: A person who ls under 18 years of age.
Ch||d-re|ated emp|oyment: Any employmenL LhaL prlmarlly lnvolves dlrecL
conLacL wlLh chlldren where LhaL conLacL ls noL dlrecLly supervlsed by a
person havlng Lhe capaclLy Lo dlrecL Lhe person ln Lhe course of Lhe
employmenL, lncludlng employmenL ln clubs, assoclaLlons, movemenLs,
socleLles, lnsLlLuLlons and oLher bodles (lncludlng bodles of a culLural,
recreaLlonal or sporLlng naLure) havlng a slgnlflcanL chlld membershlp or
lnvolvemenL.
Lmp|oyment: 1he deflnlLlon of employmenL lncludes:
performance of work under a conLracL of employmenL, or
performance of work as a self-employed person or as a subconLracLor, or
performance of work as a volunLeer for an organlsaLlon, or
underLaklng pracLlcal Lralnlng as parL of an educaLlonal or vocaLlonal
course
Not D|rect|y Superv|sed: Supervlsed refers Lo supervlslng Lhe employee's
conLacL wlLh chlldren. An employee ls noL dlrecLly supervlsed when:
Lhere ls no offlcer on slde wlLh Lhe capaclLy Lo dlrecL Lhe employee durlng
Lhelr conLacL wlLh chlldren, or
Lhere are perlods of more Lhan a few mlnuLes when Lhe employee ls noL
ln vlew of Lhls offlcer or oLher delegaLed offlcer.
Work|ng W|th Ch||dren Check: 1he Worklng WlLh Chlldren Check conslsLs of
Lwo elemenLs: excludlng people wlLh convlcLlons for serlous sex and
vlolence crlmes agalnsL chlldren, background checklng for preferred
appllcanLs for prlmary chlld-relaLed employmenL, mlnlsLers of rellglon and
auLhorlsed carers.

A|| peop|e work|ng |n, or seek|ng to work |n, ch||d-re|ated
emp|oyment must dec|are whether they are a proh|b|ted
person. 1h|s |nc|udes se|f-emp|oyed peop|e, vo|unteers and
students on p|acement. It |s an offence for proh|b|ted
persons to app|y for or otherw|se attempt to obta|n,
undertake or rema|n |n ch||d-re|ated emp|oyment.