Guardian Homecare Services (Leeds) Ltd

SENTINEL HOMECARELTD

APPLICATION FORM

Please complete all sections of this application form, once completed please return to Sentinel Homecare Limited , 2nd Floor, Hamilton House, Bradford, BD8 9TB. If you have any difficulty completing thisform please call us on 01274 541402. Please attach C.V if possible.

PERSONAL DETAILS(If you have changed your name please provide dates to and from)
Position Applied For: / Homecare Assistant
Mr./Miss/Mrs./Ms
(Please Delete) / Forenames: / Surname: / Previous
Surnames and dates:
Address:
Postcode:
Home Telephone: / Mobile Telephone:
Nationality:
National Insurance / Do you hold a valid UK/EU Driving Licence? / YES NO
EDUCATION & TRAINING(Please continue on a separate sheet if necessary)
Name/Address of School/College or workplace: / Courses or Subjects taken and qualifications gained / From
Month/Year / To
Month/Year
EMPLOYMENTHISTORY(The following must be completed in full. Start with your most recent employer.Please include all work history and explain periods of un-employment or gaps. Continue on separate sheet of paper if necessary)
Name of Manager:
Name & Address of Employer:
Telephone Landline Number: / Position Held & Brief Description of Duties:
Reason for Leaving:
Date From: / / / / Date To: / / /
May we approach the above for a reference: YES NO (Please delete as appropriate)
Name of Manager:
Name & Address of Employer
Telephone Number: / Position Held & Brief Description of Duties:
Reason for Leaving:
Date From: / / / / Date To: / / /
May we approach the above for a reference: YES NO (Please delete as appropriate)
Name of Manager:
Name & Address of Employer:
Telephone Number: / Position Held & Brief Description of Duties:
Reason for Leaving:
Date From: / / / / Date To: / / /
May we approach the above for a reference: YES NO (Please delete as appropriate)
Name of Manager:
Name & Address of Employer:
Telephone Number: / Position Held & Brief Description of Duties:
Reason for Leaving:
Date From: / / / / Date To: / / /
May we approach the above for a reference: YES NO (Please delete as appropriate)
AVAILABILITY AND CARE EXPERIENCE

Days Available to work: (Please tick appropriate boxes)

Number of Hours Wanted:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Early
Late
Nights

Care Experience:

Have you ever had experience working with or looking after people affected by any of the following, if yes please fill in the Practical Ability checklist below:

Experience with people who have: (Please tick appropriate boxes)

DementiaٱTerminal illnessٱChallenging Behaviourٱ

ElderlyٱLearning DifficultiesٱMental Health Problemsٱ

ChildrenٱPhysical DisabilitiesٱSensory Disabilitiesٱ

Others, please state: ……………………………………………………………

Practical Ability:(Please ONLY tick the tasks that you have had experience in providing)

PERSONAL CARE

Dressing/UndressingٱBathing/ShoweringٱBed BathingٱFoot careٱ

Mouth CareٱShavingٱHair CareٱEye Careٱ

Bedpans/CommodesٱIncontinence PadsٱCatheter BagsٱPressure Soresٱ

Bladder/BowelsٱColostomy BagٱCare Plansٱ

MOBILITY

Lifting & TransferringٱUse of HoistsٱWalking AidsٱBathing Aidsٱ

NUTRITION

Preparing MealsٱDietary GuidelinesٱFeeding ٱ

Others, please state: ……………………………………………………………………………………………………………………..

Immunisations

Please give dates of immunisations/vaccination for the following:

TetanusDate: []Diphtheria Schick TestDate: []

PoliomyelitisDate: []RubellaDate: []

Hepatitis BDate: []TuberculosisDate: []

Chest X-RayDate: []

Rehabilitation of Offenders Act 1974 & Theft Act 1968

The Protection of Vulnerable Adults requires us to carry out checks on police records for applicants whose assignments will give them Substantial access to Vulnerable Adults. You are advised that this post is exempt from the provision of Section 4 (2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold information about any criminal convictions which for other purposes are ‘spent’ under the provision of the Act. Any failure to disclose such convictions could result in an offer of employment being withdrawn or the employment being terminated.

Have you ever been convicted in a Court of Law and /or cautioned in respect of a criminal offence?Yes ٱNo ٱ

If yes please give details:

Please provide any additional information which you feel may be necessary in aiding your application (attach a separate sheet of paper if necessary).

PASSPORT AND WORK PERMIT DETAILS(For workers from overseas only)

Do you require a work permit to work in the UK?YesٱNoٱExpiry Date][

Passport Nationality:Place of Issue:Passport Number:

Date of Issue []Expiry Date][

Known restrictions in use:

REFERENCES:

Last Employer / Personal/Character
Name :
Job Title:
Address:
Telephone number: / Name:
Job Title:
Address:
Telephone Number:
DECLARATION

I hereby declare that the information provided on this form is complete and correct and any untrue or misleading information will give myEmployer the right to terminate any employment contract offered.

I agree that Sentinel Homecare reserves the right to require me to undergo a medical examination. (Should we require further informationand wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtainyour permission prior to contacting your doctor).

Signed: ………………………………………………………… Name:…………………………………………………..Date:……………………….

Sentinel Homecare is an employer embracing equality in race and opportunities for all staff and staff are selected on merit irrespective ofrace, sex, disability, etc. In order to monitor the effectiveness of our Racial Discrimination and Equal Opportunities Policy we would askall applicants to provide the following information by indicating the broad ethnic group to which you belong.

Please tick the appropriate category:WhiteٱBangladeshiٱBlack Africanٱ

IndianٱChineseٱPakistaniٱ

Black CaribbeanٱBlack otherٱ

Otherٱ

Please specify…………………………………………………………………

Application Form  Sentinel Homecare 1