Declaration and consent for CIW to contact Social Services Departments

Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Regulation and Inspection
Children and Families (Wales) Measure 2010 as amended by The Regulation of Child Minding and Day Care (Wales) Order 2016
and the: 
Child Minding and Day Care (Disqualification) (Wales) Regulations 2010
A copy of this form must be completed by the applicant and all persons who have attained the age of 16 years and over who live/work in the applicant’s household.

Full name and address of applicant/person who has attained the age of 16 years and over who lives/works in the household:	     	

Any alias and former names:
	     	

Postcode:	     	

Date of birth:
(dd/mm/yyyy)	     	
      Previous full addresses in the last five years:
Address 1:	Address 2:	
     	     	
Postcode:	Postcode:	
     		     	
From:	     	Until:	     	From:	     	Until:	     	

Address 3:	Address 4:	
     	     	
Postcode:	Postcode:	
     		     	
From:	     	Until:	     	From:	     	Until:	     	

Address 3:	
     

Postcode:	
     	
From:	     	Until:	     	

Have you ever been the subject of a care or supervision order? 	
Yes		No	

Have you had a care or supervision order made with respect to a child in your care? 							
Yes		No	

Have you ever been disqualified from fostering a child privately? 	
Yes		No	

If yes to any of the above, please provide details including dates and the local authority involved
     

	

Please give the following details of children who currently live with you and of those who may now live elsewhere (including those of your partner)

Full name of child	
Date of birth
(dd/mm/yyyy)	
Relationship to you	
     
	     	     	
     
	     	     	
     
	     	     	
     
	     	     	
     
	     	     	
     
	     	     	
     
	     	     	
     
	     	     	

Declaration
I confirm that the information provided above is correct and I give my consent to Care Inspectorate Wales contacting my local or any relevant Social Services Department so that the above statements may be verified and to share any other information relevant to my suitability to care for children under the age of 12 years.

Name:
	     

	Date:	     	

Signature:
	
     

Personal information
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

  Please return this form to your nearest CIW office with your application form.