HEALTH CARE ASSISTANT APPLICATION FORM

    Please complete this form and complete all sections

    Attach Photo:
     
    Position Applied for

    1. PERSONAL INFORMATION:

    Title
    Surname
    Forenames (in full)
    Address
    Mobile Phone Number
    Email address
    Date of Birth
    National Insurance Number
    Nationality
    Marital Status
    Are you eligible to work in UK?
    Do you have any Criminal convictions under the Rehabilitation of Offenders Act 1974? or pending prosecution?
    Do you have a student Loan?
    Do you have a Post Graduate Loan that is not fully paid?
    I wish to opt out of the 48 hours working week limit
    Next of kin

    2. Bank Account Details:

    Bank Sort Code
    Bank Account Number
    Bank Account Name
    Bank Name

    3. General Information:

    Do you have a valid and current Driver’s License
    Do you have any endorsements?
    Work Preference
    Shifts Preference

    4. Upload Supporting Documents:

    Copy of Passport.#
    Copy of Utility bill
    DBS Certificate
    Training certificates

    5. References:

    Reference-1
    Reference-2

    6. Data Protection Statement

    The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other purpose.

    7. Equality of Opportunity Statement

    The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

    8. Confidentiality Declaration:

    Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about our clients. On no account must information relating to identifiable client be divulged to anyone other than the manger. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information, you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in disciplinary dismissal. I have read and I understand the above and I agree to abide by the contents therein.
     
    Signed:
    Date

    9. Rehabilitation of Offenders Act:

    As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to:
    • a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or
    • b) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties
    You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.

    Records will be checked via the Criminal Records Bureau procedures
    (Please select the applicable)
    I have convictionsI have no convictions

    10. Criminal Records – Disclosure Certificate

    Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about our clients. On no account must information relating to identifiable client be divulged to anyone other than the manger. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information, you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in disciplinary dismissal. I have read and I understand the above and I agree to abide by the contents therein.

    11. Asylum and Immigration Act 1996

    Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless:
    • • That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or
    • • The person comes into a category specified by the Home Secretary where such employment is allowed Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.
     
    Are you eligible to work in the UK? (Please select as appropriate)

    12. Personal Declaration:

    I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and
    • • I give permission for any enquiries that need to be made to confirm such matters as qualifications. experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose.
    • • I give permission for the processing of the personal data contained in this form for employment purposes.
    • • I understand that any false or misleading information could result in my dismissal.
     
    Signed:
    Date