ࡱ> OSJKLMN% Z(bjbjJJ 7(xAd(xAd+ .0 0 uuuuu8d%! "- 9  $"%\ uA  AA uu4 uuuApuu uA uuupOiu  0!u%%u%uuAAuAAAAA uAAA!AAAA%AAAAAAAAA0 ;:  Arbour Care welcomes your application to join our care team. PERSONAL DETAILS (Please write in capitals) Mr Mrs Miss Ms (please circle where appropriate)First Names:Surname: Present address:Postcode:Home Telephone Number: Mobile:Email address:Skype ID:Date of Birth:National Insurance Number:TrainingNVQ 2 OR 3: Yes No (proof will be required)Details:Other qualifications (proof will be required): Yes NoDetails:Do you hold any other valid training certificates? (proof will be required) Yes NoDetails:Position applied for: Live-in Carer Emergency Contact: Name:Relationship:Address:Postcode:Home Tel. No: Work No. Mobile:Do you mind pets/animals? Yes No Do you drive? Yes No Do you have a car to use at work? Yes No How confident are you driving in the UK?Do you smoke? Yes No  Practical Experience: (please tick all that are relevant)Workplace: Use of toilet facilities: Personal hygiene: Care in clients home Continence care Bathing/showeringResidential Home Bedpan/commodes Strip wash/bed bathNursing home Catheter care Use of bath aidsHospital Convene Oral hygieneOther (specify) Stoma care Hair care Feet care Fingernail care Dressing/undressingPractical Tasks: Nutrition: Mobility:Light housework Preparing mealsMoving & handlingPersonal laundry Feeding Hoists (electric/manual)Shopping Food handling Use of walking aidsBasic cookingAdvanced cookingBed makingBed changingCare duties:Pressure care managementSimple dressingsMedication assistanceEnd of life carePlease give details of any experience gained whilst caring for your family and friends: Employment (most recent first)Dates From and ToEmployers Name & AddressPosition HeldReason for Leaving     Dates From and ToEmployers Name & AddressPosition HeldReason for Leaving     Gaps in work history: (Please list all breaks in your work history with an explanation e.g. Cared for mother, travelled abroad, time with family). Date fromDate to Reason   Voluntary experience (any work performed in the community, charitable organisation, governmental agency etc.) Dates From and ToOrganisations Name & AddressPosition HeldReason for Leaving     Equal Opportunities Monitoring Questionnaire As an equal opportunities employer, we are committed to improving the procedures and practices promoting equal opportunities in the work place prohibiting unlawful or unfair discrimination. To ensure these policies are being carried out, all members are asked to provide us with information which will be held confidentially to ensure this policy is applied. Do you consider yourself to be disabled? Yes No If you have any physical or mental impairment which may have a short or long-term effect on your ability to carry out normal day-to-day activities, please give details below. Languages spoken: Ethnic Origin: (Please tick the appropriate area)White British, Irish, European Community, Other Mixed Race White/black Caribbean, White/Black African, White Asian, OtherAsian or Asian British- Indian, Pakistani, Bangladeshi, OtherBlack or Black British Caribbean, African, OtherChineseAny other ethnic group Disclosure and Barring Service (CRB) Check It is a requirement of this position that successful applicants are subject to a Disclosure and Barring Service (CRB) Check enhanced level. Do you agree that such checks may be made concerning you: Yes No Do you require a work permit or visa to work in the UK? Yes No Do you hold a current visa or permit allowing you to work in the UK? Yes No NOTE: All successful applicants will be required to produce evidence of identity and eligibility to work (e.g. Birth certificate, Passport, Work Permit, Visa, bank statement) References: - Please provide details of two referees (including current employer), who can give information relating to your reliability and competence in a caring role. Please also provide a personal character reference from a non-family member who has known you for at least one year.Reference 1Name PositionOrganisationAddressPost CodeTelephone no: Mobile:EmailMay we approach this reference prior to interview? Yes NoReference 2NamePositionOrganisationAddressPost CodeTelephone no: Mobile:EmailMay we approach this reference prior to interview? Yes NoPersonal ReferenceNameRelationshipKnown how long: Years MonthsAddressPost CodeTel no: Mobile:EmailMay we approach this reference prior to interview? Yes NoArbour Companions & Care reserves the right to obtain further references in order to satisfy ourselves as to your suitability for employment. All references are treated in strictest confidence and will only be used in relation to providing a work assignment. Any other use will only be permitted upon written authority of the applicant. Confidentiality and Data Protection I understand that during any assignment with or arranged by Arbour Companions & Care, I may have access to confidential data and records belonging to AC&C or to its clients of both a business and personal nature. I will not disclose or use any business or personal information whether identified as confidential or not to anyone else; either during or after any assignments with or arranged by Arbour Companions & Care. Rehabilitation of Offenders Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986 which states: the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health and social care services and which is of such a kind as to enable the holder to access to persons in receipt of such services in the course of his/her normal duties. Arbour Companions & Care must ask the following question: Do you have any convictions, cautions, reprimands or final warnings that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198 Yes No Signature: Date: Declaration I declare that all the information given is true and I understand that any false or misleading information may result in the termination of my employment with Arbour Companions & Care. 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