Application FormApplying for: Care Coordinator

Please complete every section. Failure to complete every section may result in your application being rejected. Information supplied will be treated in the strictest confidence.

Download offline copy Printable A4 formrecruitment@lifecare4u.org+44 7459 186054

All applicants are given fair and equal consideration regardless of sex, ethnic origin, marital status, gender reassignment, religion, colour, race, sexual orientation, social background, pregnancy, age or disability.

Personal Details

Title

Preferred Name

Forenames*

Surname*

Home Number

Mobile Number*

Address*

Postcode*

Date moved to current address

Place of Birth

National Insurance Number

Email Address*

Position Applied For*

Date available to start working for Lifecare4u

Have you ever been known by any other names? (If yes, give each name and the dates from / to)

Are you looking to work:

WeekdaysWeekday EveningsWeekendsWeekend Evenings

Next of Kin

Name*

Relationship to you*

Home Number

Mobile Number*

Address

Email Address

Training Certificates

Have you completed training and hold a certificate for any of the following subjects? If you do not have a certificate to validate your training, do not tick yes.

Subject	Yes	No	Date Attended	Company Name
Catheter Care
Challenging Behaviour
Communication
Confidentiality
Dementia
Elderly Care
Equality, Diversity and Human Rights
Fire Safety
First Aid
Food Hygiene
Health & Safety
Infection Control
Learning Difficulties
Medication Administration
Moving & Handling
Multiple Sclerosis
Palliative Care
Parkinson’s Disease
Personal Care
Safeguarding Vulnerable Adults
Sensory Impairment
Stoma/Colostomy Care

Areas of Competency

Do you have experience or knowledge in any of the following areas? Rate your level of competency.

Subject	Poor	Good	Very Good	Excellent
Catheter Care
Challenging Behaviour
Dementia
Elderly Care
Fire Safety
First Aid
Food Hygiene
Health & Safety
Infection Control
Learning Difficulties
Medication Administration
Moving & Handling
Multiple Sclerosis
Palliative Care
Parkinson’s Disease
Personal Care
Safeguarding Vulnerable Adults
Sensory Impairment
Stoma/Colostomy Care

Care Experience

How many months/years of social care experience do you have in total?

How many months/years working in the following areas?

Live-in Care

Domiciliary / Homecare

Nursing / Residential Home

Hospital / NHS

Other (please specify)

Self-Rated Skills

Skill	Poor	Good	Very Good	Excellent
Ability to communicate clearly
Ability to use your initiative
Ability to work unsupervised
Ability to work with others
Ability to act calmly and professionally during a difficult/emergency situation
Cleaning
Cooking
General running of a household

Languages and Availability

What is your first language?

Other languages spoken (if any)

Notice period to serve with current employer (if any)

Holidays already arranged this year (please specify dates)

How far would you be prepared to travel to a client's house?

What qualities do you possess that you believe will make you a good carer and companion?

Hobbies and interests

Education

Secondary Education

School name and address

Subjects studied and exam results achieved

Further Education and Training

Have you completed a QCF or NVQ in Health and Social Care?

Yes No

Date Achieved

Level of Award

Other Qualifications

From

Brief description of role and responsibilities

Reason for Leaving

Gaps in Employment

Please provide an explanation for any gaps or breaks in employment (include From, To and Reason)

References

We will contact previous employers for references but in some cases require further character references. Please provide contact details for two people that are not members of your family.

Referee 1

Name of Referee

Relationship to you

Address

Postcode

Contact Number

Email Address

Referee 2

Name of Referee

Relationship to you

Address

Postcode

Contact Number

Email Address

Statement of Fitness for Work

The Health and Social Care Act 2008 (Regulated Activities 2010) requires that the worker is “physically and mentally fit for that work”.

I declare that I am physically and mentally fit for the role of a Carer as detailed in the Carer Role Profile.

Print Name*

Signed (type your name)*

Date*

Please declare any physical or mental conditions that may affect your ability to carry out the role (Schedule 3, Regulation 21)

DBS Declaration

All applications for employment with Lifecare4u Limited are subject to an Enhanced DBS.

I confirm that, to the best of my knowledge, the information given above is true and correct. I am aware that my application is subject to an Enhanced DBS check, and that adverse information may result in my application being rejected.

Print Name*

Signed (type your name)*

Date*

European Working Times Directive

The European Union has laid down guidelines for all workers governing the length of hours worked in a week. You are under no obligation to accept work offered and will not be compelled to work more than 48 hours a week, but you may choose to do so.

Please indicate your preference:

I wish to work more than 48 hours a week.I do not wish to work more than 48 hours a week.

Print Name*

Signed (type your name)*

Date*

Data Retention

If you are unsuccessful in this application, we will keep this form on file for 6 months should you wish to be considered for other vacancies within Lifecare4u.

I agree to my application being kept on file for 6 months.

By submitting this form, you confirm that all information provided is accurate to the best of your knowledge.

Application FormApplying for: Care Coordinator

Personal Details

Next of Kin

Further Details

Training Certificates

Areas of Competency

Care Experience

Self-Rated Skills

Languages and Availability

Education

Secondary Education

Further Education and Training

Other Qualifications

Employment History

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

Employer 6

Gaps in Employment

References

Referee 1

Referee 2

Statement of Fitness for Work

DBS Declaration

European Working Times Directive

Data Retention

Equal Opportunities Monitoring