Application For Matron's Licence

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