Are you permitted to work in the UK?

Yes

No

Can you provide evidence to prove eligibility?

Yes

No

What visa/permit/status do you currently hold?

Working Holiday

Work permit

Leave to remain

Other (specify below)

Do you have full Driving Licence that allows you to drive in the UK?

Yes

No

Do you have access to a car that you can use for work?

Yes

No

Have you been banned from driving or do you have any current endorsements on you licence?

Yes

No

Does you car insurance include Class 1 business insurance? (in order to use you vehicle for work you must have class 1 business insurance)

Yes

No

Are all your documents up to data and valid?

Yes

No

From

To

Employer

Position

Duties

Last salary

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Institution

Course

Year

Grade

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Please check the training(s) you have completed:

Basic life support

DOLLS & Mental Capacity

Diploma in Health & Social Care L2

Diploma in Health & Social Care L3

First Aid

Health and Safety

Infection Control

Manual Handling

Medication

Have you or have ever suffered from long term illness?

Yes

No

Have you ever required sick leave for a back or neck injury?

Yes

No

Do you suffer with any back or neck injuries?

Yes

No

Have you been in contact with anyone who is suffering from a contagious illness within the last six weeks?

Yes

No

Do you suffer with a communicable disease?

Yes

No

Are you currently receiving active medical attention?

Yes

No

Are you registered disabled?

Yes

No

GP details

Name

Address

City

County

Zipcode

Country Please selectAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland Islands [Malvinas]Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of North MacedoniaRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

May we contact your Doctor for health check?

Yes

No

The above information will be held in strict confidence. If you aware of any health issue that you feel may affect your ability to undertake responsibilities of the post it is your responsibility to inform the Care Manager immediately. Again any details discussed in the meeting will be held in strict confidence.

I understand that my GP may be contacted for details about my health.

DBS Declaration

Do you have a current DBS (Disclosure Barring Service) certificate?

Yes

No

Please enter disclosure number

Date of issue

Reference Number (if applicable):

I understand that a DBS check will be sort in the event of a successful application.