Please make sure you have read “Your Guide To Applying For A Job With Us” before completing this form.

Application for the post of:
Applicant Reference No (office use only):
Surname / First Name
Address Line 1:
Address Line 2:
Address Line 3:
Postcode:
Application for the post of:

Personal Details

Home Number: / Mobile Number:
E-mail Address:
Relationships
Are you related to, or have a relationship with, a trustee or employee of Bluebell Wood Children’s Hospice? If so, please state the relationship:
I confirm that I am eligible to work in the UK / I confirm that I am 16 years of age or over

Criminal Convictions

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975
Due to the nature of the service we provide, Bluebell Wood is exempt from the provisions of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975.
Applicants are not entitled to withhold any information about convictions, cautions, warnings and reprimands for which any other purposes are spend under the provisions of the Act. Any information supplied will be treated in the strictest of confidence and will be considered only in relevance to an application for positions to which the Rehabilitations of Offenders Act 1974 (Exceptions) Order 1975 and the Legal Aid, Sentencing and Punishment of offenders Act 2012, applies.
Applicants to certain jobs who are offered employment will be subject to a criminal records check from the Disclosure & Barring Service before the appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions. Bluebell Wood abides by the DBS Code of Practice, which means any conviction disclosure would not necessarily be a bar to employment, but failure to disclose information relating to any convictions etc. could lead to withdrawal of an offer of employment.
Have you ever received a criminal conviction, caution, warning, reprimand or bind over? / Yes / No
If so, please give details:

Disciplinary Proceedings

Please provide details of any disciplinary actions or investigations that you have been subject to, that are ongoing or still live on your records

References

Please see “ Your Guide to Applying for a Job with Us” for guidance on references.

Please note, all reference requests will be sought and employment histories verified by the HR Team, therefore, please ensure that you provide full contact details. Referees will only be contacted when a job offer has been made.

Referee 1 Referee 2

Name / Name
Company Name / Company Name
Address / Address
Phone Number / Phone Number
Email Address / Email Address
Relationship / Relationship
Application for the post of:
Applicant Reference Number: (Office use only)

Employment History

Name and address of current or most recent employer / Present or Most Recent Post(include Job Title and Brief Description of Duties)
Reason for Leaving
Salary / Date of Appointment / Date of Leaving
(if applicable) / Notice Period

Previous Employment

Please provide a full employment history, with the most recent shown first (i.e. the one immediately prior to the present post above). Please continue on a separate sheet if necessary.

Employers Name and Address / Post Held and Brief Description of Duties / From / To / Reason for leaving

Education

Name of School / College / University / From / To / Subject / Qualification Gained / Grade / Year

Other Relevant Training

Subjects / Date(s)

Membership of Professional Bodies

Name of Professional Body:
Membership registration/pin number:
Expiry/renewal date:

If you are a member of more professional bodies, please attach an extra sheet.

Supporting Statement

Please give a brief summary of any experience and training which you feel is relevant to the post. A CV or supplementary information will not be considered when shortlisting. Please read the Job Description and Person Specification carefully, as the information you give us will be matched against the Essential and Desirable requirements.
Please continue on a separate sheet if necessary

Thank you for completing this form.


EQUAL OPPORTUNITIES MONITORING FORM

At Bluebell Wood Children’s Hospice we aim to eliminate direct or indirect discrimination, as covered by the Equality Act 2010, on grounds of; age, disability, gender reassignment, marriage, civil partnership, pregnancy, maternity, race, religion, belief, sex or sexual orientation.

Please could you take a few moments to complete this form; the information is used solely for monitoring purposes and is separated from the rest of the application form before the interview.

Applicant Reference No: (Office use only)
Where did you see the position advertised?

PLEASE PLACE A “X” IN THE APPROPRIATE SECTION

GENDER

Would you describe yourself as: / Male / Female
Transgender / Prefer not to say
Does your gender differ from that you were originally assigned at birth? / No / Yes / Prefer not to say

AGE

What is your age group? / Under 25
25-34
35-44 / 45-54
55-64
65 or over
Prefer not to say

DISABILITY

*According to the Equality Act 2010, a person has a disability if they have a physical or mental impairment and the impairment has a substantial and long-term adverse effect ontheir ability to perform normal day-to-day activities.

If invited to interview do you have any special requirements, e.g. Wheelchair access? / Yes / No
If yes, please specify.
Do you consider that you have a disability or a long-term health condition? / Yes / No / Prefer not to say
What is the effect or impact of your disability or health condition on your ability to give your best at work?

SEXUAL ORIENTATION

What is your sexual orientation? (Please tick the box that best describes you)
Bisexual
Gay Man
Gay Woman/ Lesbian) / Heterosexual / Straight
Other (please state)
Prefer not to say

RELATIONSHIP STATUS

How would you describe your relationship status? / Co-habiting / Civil Partnership / Married
Single / Prefer not to say

ETHNICITY

(The following sets of categories are for monitoring main characteristics from an equality and diversity perspective that will help us ensure that our policies and practices do not inadvertently discriminate against you. We will ensure that any information you provide here will only be used to monitor the effectiveness of our policies and will ensure the information remains confidential to the HR Team.)

How would you describe yourself? (Choose ONE section from A to E, and then tick the appropriate box)
A - Asian or Asian British / B – Black/African/Caribbean/Black British
Bangladeshi
Indian
Pakistani
Chinese
Prefer not to say
Any other Asian background (please state) / African
Caribbean
Prefer not to say
Any other Black/African/Caribbean background (please state)
C - White / D – Mixed/multiple ethnic groups
British
English
Irish
Northern Irish
Scottish
Welsh
Gypsy or Irish Traveller
Prefer not to say
Any other white background (please state) / White and Asian
White and Black African
White and Black Caribbean
Prefer not to say
Any other mixed background (please state)
E – Other ethnic group
Arab / Prefer not to say / Any other ethnic group (please state)

RELIGION OR BELIEF

Please tick the box that best describes you:
Buddhist
Christian
Hindu
Jewish
Muslim / Sikh
Other Religion or Belief (please state) …………………………………………………………..
No Religion or Belief
Prefer not to say