Staff Application Form 02

Personal Details

First Name *

Middle Name

Last Name *

Any Previous Name

Address1 *

Address2

Town

Post Code

DOB *

Home Phone *

Mobile

Email Address *

Next of Kin Contact Details

Name Of Next Of Kin

Relationship To You *

Address of next of kin *

City

Post Code

Contact Details

Health Questionnaire

Do you have any medical conditions that may affect your working with in the role ou are applying for? *

Do you have any disability necessitating special aids, or requirements, for access to premises? *

How many days' absence through sickness have you had in the lst 24 months ? *

How many days's absence have you had for other reasons in the last 24 months? *

Have you ever?

Undergone a surgical operation or been admitted to hospital for any reason? *

Been seriously ill or injured? *

Been refused, or lost your employment for health reasons? *

Been made ill by your work? *

Been refused a driver's licence on grounds of ill health? *

Been, or are, a Registered Disabled Person? *

Signature *

STAFF DISQUALIFICATION DECLARATION

A person may be disqualified through:

1. Having certain orders or restrictions placed upon them.

2. Having committed certain offences, you are required therefore to complete the form and the declaration below. In so doing you are confirming that you are not disqualified under those Regulations from working in a Child Workforce Setting.

Staff Name *

Current Job Title: *

Main Responsibilities of your current role *

Orders or Other Restrictions

Have any orders or other determinations related to children under your care been made in respect of you? *No

Have any orders or other determinations related to childcare been made in respect of a child in your care? *No

Are you barred from working with Children (Disclosure and Barring (DBS)? *No

Specified and Statutory Offences

Have you been cautioned (including a reprimand or warning) since have you been convicted of 6 April 2007 or have you been convicted of:

b) Any violent* or sexual offence against an adult? * A violent offence in this context is murder, manslaughter, kidnapping, false imprisonment, ABH, GBH. *No

c) Any offence under the Sexual Offences Act? *No

d) Any other relevant offence? *No

Have you ever been cautioned, reprimanded, given a warning for or convicted of any similar offence in another country? *No

Provision of Information

If you have answered YES to any of the questions above you should provide the details below in respect of yourself. You may supply this information separately, if you so wish, but you must do so without delay.

Date of the order, restriction, conviction, caution etc.

The date(s) of these

The relevant court(s) or bod(ies)

You should also provide a copy of the relevant order, caution, conviction etc. In relation to cautions/convictions a DBS Certificate may be provided.

Signature *

CONFIDENTIALITY AGREEMENT

All members of Staff are required to agree to the following statements relating to confidentiality.

Staff Name

Signature *

DOCUMENTS CONFIRMATION

Staff Name:

I confirm that I have received, read, understood, have working knowledge and will put in to practice the following documents:

Signature *

Save and continue later

Staff Application Form 2

Personal Details

Next of Kin Contact Details

Health Questionnaire

Have you ever?

STAFF DISQUALIFICATION DECLARATION

A person may be disqualified through:

Orders or Other Restrictions

Specified and Statutory Offences

Have you been cautioned (including a reprimand or warning) since have you been convicted of 6 April 2007 or have you been convicted of:

Provision of Information

If you have answered YES to any of the questions above you should provide the details below in respect of yourself. You may supply this information separately, if you so wish, but you must do so without delay.

CONFIDENTIALITY AGREEMENT

All members of Staff are required to agree to the following statements relating to confidentiality.

DOCUMENTS CONFIRMATION

07732777886

info@primeplusuk.co.uk

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