Application Form

Lifecare4u Limited — Professional Home Care Services

All applicants will be 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. The information supplied in this document will be treated in the strictest of confidence. Please complete this form in block capitals using black ink.

PLEASE COMPLETE THIS FORM USING BLACK INK AND ENSURE THAT EVERY SECTION HAS BEEN COMPLETED. FAILURE TO COMPLETE EVERY SECTION MAY RESULT IN YOUR APPLICATION BEING REJECTED.

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, please give details of each name and the dates from and to the name was used):

Are you looking to work:

Weekdays Weekday Evenings Weekends Weekend Evenings

Next of Kin

Name:

Relationship to you:

Home Number:

Mobile Number:

Address:

Email Address:

Further Details

If you have answered yes to any of the questions, please provide further details.

Question	Yes	No	Details
Do you require a Visa or Work Permit to work in the UK?			Type: ____________ Issue: ________ Expiry: ________
Do you hold a full UK driving licence?			Issue: ________ Expiry: ________
Do you hold a driving licence issued in any other country?			Country: ________ Issue: ________ Expiry: ________
Do you have any points or endorsements on your driving licence?			Details: ____________________________
Do you have use of your own vehicle?
Are you able to drive automatic and manual cars?

Relevant Skills and Experience

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, please do not tick yes.)

Subject	Yes	No	Date Course 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

Do you have experience/knowledge in any of the following areas? How would you 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

How many months/years 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):

How would you rate your skills in the following areas?

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

What is your First Language?

Do you speak any other Languages? (if yes, please specify):

Do you have a notice period to serve with your current employer? (If yes, please specify):

Do you have any holidays arranged for the current year? (If yes, 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?

What are your hobbies and interests?

Education

Secondary Education

School Name and Address	Subjects studied and exam results achieved

Further Education and Training

Question	Yes	No	Date Achieved	Level of Award
Have you completed a QCF or NVQ in Health and Social Care?

Other Further Education and Qualifications

University/College	Subject	Qualification Achieved

Employment History

We require a full employment history since you left full-time education in order to comply with current regulations. You must account for any gaps in employment and explain your reason for leaving each employment. Please begin with your most recent employer and continue on an additional sheet if necessary. By completing this section you agree to Lifecare4u obtaining references and release Lifecare4u and all referees from any liability caused by giving or receiving information in relation to your suitability for the position you are applying for.

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Name of Employer:

Full Address of Employer:

Name of Line Manager:

Contact Number:

Email:

Job Title:

From:

To:

Final Salary:

Brief description of role and responsibilities:

Reason for Leaving:

Employment History — Gaps in Employment

Please provide an explanation for any gaps or breaks in employment in the table below:

From	To	Reason

References

We pride ourselves on the quality and suitability of our Carers for their role. 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:

Address:

Postcode:

Contact Number:

Email Address:

Relationship to you:

Referee 2

Name of Referee:

Address:

Postcode:

Contact Number:

Email Address:

Relationship to you:

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:

Signed:

Print Name:

Date:

In accordance with The Health and Social Care Act 2008 (Regulated Activities 2010) Schedule 3, Regulation 21, you are required to declare any information about physical or mental conditions which may affect your ability to carry out your role. Please give a detailed explanation of any such condition below:

DBS Declaration

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

I can 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. Should this disclosure reveal any adverse information not previously divulged I fully understand that my application for employment could be rejected.

Print Name:

Signed:

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 confirm that you have read and understood the above by indicating your preference by deleting the relevant text below.

I DO / DO NOT WISH TO WORK MORE THAN 48 HOURS A WEEK

Print Name:

Signed:

Date:

Thank you for taking the time to complete this form. We appreciate the extensive length and detail of this application form; however, this will help us to deal with your application more efficiently.

The Data Protection Act 1998 requires that any staff handling personal data must follow certain principles in relation to the data that they hold. Individuals have rights of access to data that is held and rights to claim for damages if various offences occur. This covers manual as well as computerised records. In implementing the legislation, Lifecare4u adopts a simple and straightforward policy.

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.

Please tick to show your agreement to this.

Equal Opportunities Monitoring

This information will not be used during our selection process.

Position applied for:

Sex: Male Female

Surname:

Forenames:

Title:

Marital Status:

Date of Birth:

Nationality:

What is your ethnic group?

White: British Irish European Other White background

Mixed: White & Black Caribbean White & Black African White & Asian Other Mixed background

Black or Black British: Caribbean African Other Black background

Asian or Asian British: Indian Pakistani Bangladeshi Other Asian background

Chinese or other Ethnic Group: Chinese Any other

Do you consider yourself to have a disability? Yes No

If yes, please specify disability and any requirements that would assist you in applying for or carrying out this role: