DECD SA
National School Chaplaincy Program (NSCP)
Certification
Privacy Statement
Information collected in this form will be used to administer the NSCP in South Australia. The information may
also be used for research and evaluation of the Program.
DECD will provide the names of schools which receive funding, and appointed Pastoral Care Workers to CESA,
AISSA and the Department of Education and Training, but will not otherwise use or disclose personal
information collected in this form unless authorised or required by law or by specific permission.
Please complete and return this form by email to Krisha Brandon at DECD.chaplaincy@sa.gov.au
by COB Friday 27 March 2015.
SCHOOL NAME: ______________________________________________________________________
PRINCIPAL NAME: ____________________________________________________________________
DELEGATE NAME (if appropriate): _______________________________________________________
SERVICE PROVIDER NAME: ____________________________________________________________
Please tick each item below and sign the document to confirm that
you are meeting the NSCP requirements.
I confirm that:
[ ] The Service Provider is the employer of the chaplain – not the department or any individual school.
[ ] The Service Provider meets the criterion of being an ‘accepted religious institution’ to be able to endorse
Pastoral Care Workers as per the terms of the National School Chaplaincy Program 2015-2018 Project Agreement.
APPOINTED PASTORAL CARE WORKER NAME: ___________________________________________
Note: Within DECD, chaplains are called Pastoral Care Workers
COMMENCEMENT DATE: ____________________________________________________________
1 | DECD SA National School Chaplaincy Program Certification | 5 March 2015
I confirm that the Pastoral Care Worker utilised by this site provided the following evidence:
[ ]
they are recognised and supported by their school community
[ ]
ordination, religious qualification or endorsement by an accepted religious organisation
[ ]
academic qualifications that meet the program requirements.
I have sighted and recorded:
[ ] a current DCSI - Child Related Employment Clearance
[ ] current Responding to Abuse and Neglect Training – Education and Care;
[ ] Certificate IV in Youth Work; or Certificate IV in Pastoral Care; or an equivalent qualification which must
include competencies in 'mental health' and 'making appropriate referrals' (as per the Instructions and Frequently
Asked Questions document and Information for schools - Employing A Pastoral Care Worker)
I declare that:
[ ] I have read, understood and complied with the South Australian NSCP guidelines (titled DECD National School
Chaplaincy Program Instructions and Frequently Asked Questions) including, but not limited to, the qualification
requirements and religious status of the person appointed as a Pastoral Care Worker and all legislative and policy
requirements related to child safety.
[ ] Appropriate steps have been taken to ensure all stakeholders are aware that participation in this program is
voluntary and that adequate permission arrangements are in place to confirm prior parental/guardian consent.
[ ] A satisfactory Complaints Process is in place and promoted to the school community.
[ ] A signed Code of Conduct is in place.
Note: A sample Code of Conduct may be found in the Guidelines document at page 10.
[ ] There is consultation with, and ongoing support from, the broader school community about the demand for,
and role of, a Pastoral Care worker.
[ ] Ongoing consultation with the school community will occur on an annual basis at a minimum to assess the
demand, support for, and nature of Pastoral Care Worker services.
[ ] I will provide all information and evidence related to the NSCP on request by DECD.
[ ] I will ensure that the service provider is paid NSCP funding in full upfront inclusive of GST by the end of
term 1, 2015.
[ ] I will participate in any NSCP evaluation activities undertaken by DECD/Commonwealth Department of
Education and Training.
2 | DECD SA National School Chaplaincy Program Certification | 5 March 2015
__________________________________________
__________________________________________
Signature of the Principal making this declaration
Witness signature
__________________________________________
__________________________________________
Name of Principal (please print)
Name of Witness (please print)
Date: _____________________________________
Date: _____________________________________
3 | DECD SA National School Chaplaincy Program Certification | 5 March 2015