Disclosure of Criminal Conviction(s) Questionnaire

Confidential to the Leeds City College Admissions Office

Please insert your details below: 

Name:   		
Student Ref. No:  	
Course applied for: 
 	
Please complete both sides of this questionnaire and return in the prepaid envelope provided. When we receive your questionnaire we will assess the details of your conviction(s) and your application will either be referred to the curriculum area for a course interview, or in certain circumstances you may be invited for an initial meeting to discuss your conviction(s) in more detail. We will contact you to arrange a private and confidential meeting with a member of the College management team if this is necessary.  

If you have ticked this form in error				Please return the form in the Freepost
please tick here:           					envelope 

Please list the date and nature of each offence, and the penalty:
Date of offence:	Nature of offence:	Sentence and/or penalty:	

	    		

			

If you are currently in detention, please tell us where, and your expected release date below.

Name & Address of Prison/YOI: ………………………………………………………………………………….

Tel no: ……………………………………   Your expected release date: ……………………………………..

Continues Overleaf

Please use the space below to describe the circumstances of the offence(s):

Please include any details which you feel might be useful, for example, how old you were when the offence happened, any mitigating or special circumstances which might have affected your behaviour etc. This is often our first impression of you, so please take time to fill out this section fully (use an extra sheet of paper if you need to).

If you have a Probation Officer (PO) or Youth Offending Team Worker (YOTW) please give their full name, contact telephone number(s) and the location/centre they work from below.
Full Name: ……………………………………………………………………………………….…………………   
Tel No(s):  …………..……………………………………   ……………………………………………………
Address/Centre they work from: ……………………………………………………………………………….
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
This is essential if you are currently working with a PO or YOTW, or finished working with them in the last 12 months. We may contact your PO/YOTW to verify the information you have given us, and for a reference as to how you have engaged with the work you have done with them.  Please be aware that by signing below you are giving your permission for this information to be disclosed to Leeds City College. 
Failure to supply this information will likely result in a delay to your application

If you have a Probation Officer (PO) or Youth Offending Team Worker (YOTW) please give their full name, contact telephone number(s) and the location/centre they work from below.

Full Name: …………………………………………   Tel No(s): …………..……………………………………

Address/Centre they work from: ……………………………………………………………………………….

…………………………………………………………………………………………………………………………

This is essential if you are currently working with a PO or YOTW, or finished working with them in the last 3 years. We may contact your PO/YOTW to verify the information you have given us, and for a reference as to how you have engaged with the work you have done with them. 
Please be aware that by signing below you are giving your permission for this information to be disclosed to Leeds City College. 
Failure to supply this information will likely result in a delay to your application.

PO/ YOW Name: …………………………………………………..

If you have a Probation Officer (PO) or Youth Offending Team Worker (YOTW) please give their full name, contact telephone number(s) and the location/centre they work from below.

Full Name: …………………………………………   Tel No(s): …………..……………………………………

Address/Centre they work from: ……………………………………………………………………………….

…………………………………………………………………………………………………………………………

This is essential if you are currently working with a PO or YOTW, or finished working with them in the last 3 years. We may contact your PO/YOTW to verify the information you have given us, and for a reference as to how you have engaged with the work you have done with them. 
Please be aware that by signing below you are giving your permission for this information to be disclosed to Leeds City College. 
Failure to supply this information will likely result in a delay to your application.

PO/ YOW Name: …………………………………………………..

Please sign and date the form below:

Your Signature: ………………………………………………………..    Date: …………………………….