Candidates

Phone

Job Role *

Title

First Name *

Last Name *

Contact Number *

Email Address *

Address *

National Insurance Number *

Evidence Of Attendance Of A Safeguarding Child Protection/Vulnerable Adult Course *

Yes No

Evidence Of Attendance Of A Recent CPR/First Aid Resuscitation Course *

Yes No

Do You Have A Recent DBS *

Yes No

Are You Able To Take Up Employment In The UK With No Current Immigration Restrictions *

Yes No

Health Declaration

Have You Ever Had Or Do You Currently Suffer From: *

Asthma, Bronchitis, Tuberculosis, And/Or Other Diseases Of The Lungs?

High Blood Pressure, Chest Pains, Palpitations, Varicose, And/Or A Heart Condition?

Depression, Anxiety, Breakdowns, Epilepsy, Fits, Giddiness, And/Or Fainting

Blackouts And Or Migraines

Back Pains, Arthritis, Rheumatism, And/Or Gout

Stomach Disorders, Colitis, Diarrhoea, Hepatitis A, B, Or C, And/Or Bladder, Kidney Or Any Other Abdominal Disorders

Any disorders Of The Eyes, Ears, Nose, And/Or Throat

Diabetes, Thyroid Disorders, And/Or Any Other Glandular Disorders

Dermatitis, Skin Allergies, Psoriasis, And/Or Eczema

Chicken Pox Or Shingles

Other

None

Tick All In which You'd Answer "Yes"

Have You Ever Had Or Been Exposed To Any Infectious Diseases: *

MRSA, Hepatitis, AIDS

Other

None

Have You Had Any Surgical Operations Or Suffered Any Major Illnesses

Yes No

Are There Any Medical Disorders That Are common In Your Family History

Yes No

Are You Currently Taking Any Prescription Drugs?

Yes No

Have you Had The Need To Seek Medical Assistance In The Last 5 Years

Yes No

Have You Been Absent From Work With Sickness In the Last Twelve Months

Yes No

Vaccinations *

Hepatitis B

COVID19

Influenza

Varicella

Tuberculosis Including BCG

Rubella (German Measles)

HIV

Tetanus

Typhoid

Poliiomyelitis

Heaf, Mantoux Or Tine

Other

Tick All Vaccinations You Have Had (We may ask for evidence where required)

Next Of Kin *

Next Of Kin's Telephone *

Next Of Kin's Address *

GP Name *

GP Telephone *

GP Address *

Disclaimer & Authorisation

I Confirm That The Details Specified Above Are Factual, And Consent To Excellent Care 1st Contacting My GP, Where Necessary, In Order To Obtain Further Information On My Health Status And/Or To Request A Certificate Of Fitness

Do You Have Any Convictions That Are Unspent Under The Rehabilitation Of Offenders Act (1974) *

Yes No

Do You Have A Disability Which Is Relevant To Your Application *

Yes No

Will We Need To Make Any Specific Arrangements In Order For You To Attend The Interview *

Yes No

Are You Able To Supply Two References? *

Yes Can Supply One

Documentation:

I Have Read And I Agree With The Details Laid Out In The Privacy Policy And The Terms Of Use

By Entering Your Name Below, You Consent To Digitally Signing The Above Information In Confirmation That The Details Are Correct And Factual *

Due to the size of the form, you may need to wait after submission. - You will see a submission message when completed

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