Application For Matron's Licence

APPLICATION FOR MATRON’S LICENCE.
CHILDREN AND YOUNG PERSONS ACT. 1963
CHILDREN (PERFORMANCE) REGULATIONS. 1968
All information given in this application form will be treated in confidence, other
than information relating to criminal offences. Please complete this form in type
of block capitals.
“Any person who knowingly or recklessly makes any false statement in or in
connection with this application for a licence…..shall be liable on summary
conviction to a fine not exceeding £1000, or imprisonment for a term not
exceeding three months or both” (Children and Young Persons Act 1963, Pt. 11,
Sect. 40)
“The Licensing Authority shall not approve a matron (chaperone) unless they are
satisfied that she/he is suitable and competent…” (Regulation 12(2), Children
(Performance) Regulations 1968)
Surname:
Mr. Mrs. Miss. Ms. Other.
First Names:
Date Of Birth:
Place of Birth:
Address, Including
Full post code:
TelephoneNo:
Mobile No:
How long at this Address:
If less than 5 years please
List all previous addresses:

Present Employer
Address:
Type of Work:
Professional Qualifications:
Have you ever been approved Yes No
As a Matron?
Are you a Registered Child Yes No
Minder or Foster Carer?
If yes to either of these questions
Please give the name and address of
The Licensing Authority.
Do you have a current First Aid Qualification? Yes
No
Do you have a Full Driving License? Yes No
Would your car insurance allow you
To carry passengers whilst you are Yes No
Employed as a Chaperone?
Are your Registered Disabled? Yes No
Please give Reg. Number.

REFEREES
Please give the names, addresses and phone numbers of two responsible
persons who would be prepared to give you references as to your suitability to
be a matron. At least one of these should know you in a professional capacity.
Please state in what capacity the person is known to you.
1.
2.
Due to the nature of the work, we need to know if you have ever been
convicted of a criminal offence, including any traffic offences:
Have you been convicted of a criminal offence? Yes No
If Yes please give details below.
Date: Court/Offence/Result
Please give details of any other relevant work experience (e.g. teaching, Social
work, youth work nursery nurse etc.) or if you have acted in a voluntary
capacity, such as with cubs/brownies. Please also add anything else that you
may wish to add in support of this application. You may wish to continue on
another sheet if necessary.

Your name will appear on a list of the LEA’s approved matrons, unless you
indicate otherwise; do you agree to your name being placed on this list?
Yes
No
DECLARATION TO BE SIGNED BY THE APPLICANT,
I hereby declare that the above information is true, to the best of my
knowledge. I understand that I would be liable to prosecution if I wilfully
stated in it anything, which I knew to be false, or did not believe to be true.
Signed. _________________________________Date. _________________________
INFORMATION SHARING AND PHOTOGRAPHS – Data Protection Act.
The photographs supplied with the application will be used and stored for the
sole purpose of providing a license to act as a Matron (Chaperone).
(Photographs will be scanned and stored with personal information
electronically).
THE ORIGINAL PHOTOGRAPHS WILL NOT BE RETURNED TO YOU
AND WILL BE DESTROYED WHEN THEY ARE NO LONGER NEEDED FOR
THE PURPOSE THE IMAGES WERE PROVIDED FOR.
In order to use the images, Sefton Children’s Services require your consent for
the use and storage of this information.
I consent for my images (Photographs) to be used as above:
Signed: ________________________________________________
The application will apply for three years, and must be renewed after that
time.
This form should be returned together with three passport size photographs
Attendance & Welfare Service,
Town Hall,
Oriel Road,
Bootle,
Liverpool,
L20 7AE