Landsker Child Care

                            Personal Circumstances

Position applied for
Name
Nationality
National Insurance No
Address
Post Code
Telephone No
Mobile No
How did you hear about us?
	Activities and Interests
What clubs, societies, organisations do you belong to?
Any positions of responsibility?
If you had more time / money, what hobbies would you like to take up?

    Education & Training

Schools attended from age11
Examination results
Further education colleges
Qualifications, including vocational training
Are you registered with the Care Council for Wales? Please provide your registration number.
	Work Experience
	Please provide full details of your employment for the past 10 years. List and account for any gaps in employment.
Employer
Position
Address
Salary
Reason for leaving
Dates	from to
Employer
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Address
Salary
Reason for leaving
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Salary
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Employer
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Salary
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Employer
Position
Address
Salary
Reason for leaving
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Employer
Position
Address
Salary
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 Health & Fitness for Work

Please provide details of any disability or injury, which may affect your ability to work.
Please give details of any injury you have suffered whilst at work.
Are you receiving physiotherapy or similar treatments?
Are you being prescribed any form of medicine or drugs?
Have you had any time off for stress or stress related illnesses in the past 10 years? Please provide details.
How many absence days off have you had in the past 12 months?
Do you smoke?
Are you registered disabled?
Are you colour blind?

    For CRB checks, we require your addresses for the last 5 years  

Address
Post Code
Date from
Date to
Address
Post Code
Date from
Date to
Address
Post Code
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Date to
Address
Post Code
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Address
Post Code
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Address
Post Code
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  Other Matters

Do you have a current full driving licence?
What is your notice period?
Do you have any holiday commitments?
Are there any other key factors that may affect your regular attendance at work?

      Offending History

Have you ever been convicted of a criminal offence, had a caution, reprimand, or a police investigation that may raise questions as to your suitability? Please provide details.

 (You do not have to declare any spent convictions as defined under the Rehabilitation of Offenders Act 1970).  Please note that any offer of employment will be subject to a full disclosure via the Criminal Records Bureau.
         References Please provide details of 3 people we can contact for a reference, including a previous employer where possible. 

Name
Address
Telephone No
Telephone check
Name
Address
Telephone No
Telephone check
Name
Address
Telephone No
Telephone check

 Please list below any Care Homes that you have worked in with their contact details. We reserve the right to take up references from any or all of these homes.  

Care Home	Address / Telephone number

Further Information

Please use this space to add any further information you think relevant to support your application including why you believe you have something to offer this organisation .
DeclarationThe information on this form is true. I understand that if I am offered a job and I have given false or misleading information this would lead to a withdrawal of the offer, or dismissal without notice if I have already commenced work. I also understand that any offer and the resulting employment will be conditional on satisfactory references, Criminal Records Bureau checks and registration by the Care Council for Wales.
Agree?
Date

Landsker Child Care Health Screening Check 

Name :
Date of Birth :
Sex :
Name of G.P. :
Address :
Tel No :
Next of Kin :
Relationship :
Address :
Tel No. :
Details of previous serious illnesses, injuries & allergies :
Details of any regular prescriptions :
Inoculations :
Tetanus Date : Tuberculosis   Date : Hepatitis B Date :  Diphtheria  Date : Rubella Date : Polio  Date : Whooping Cough Date : Measles  Date : Mumps Date :
It is strongly recommended that all inoculations are up to date to protect you from any unnecessary risk. I agree the above statement is a true and accurate record. Please note any falsification may effect your employment rights.
Agreed?
Date