Employment Application Form Adult Social Care Personal DetailsFull Name:Phone Number:Email Address:Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal codeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweRight to Work in the UK:YesNoPosition Being Applied ForSupport WorkerSenior Support WorkerTeam LeaderRegistered ManagerAdminDriverExperience & QualificationsExperience working with children/young people:Qualifications (NVQ, Care Certificate, Youth Work, etc.):Safeguarding training completed:YesNoFirst Aid training completed:YesNoMedication training completed:YesNoDriving Licence:YesNoEmployment HistoryAre you currently Employed or have you ever been Employed?YesNoEmployment History 1Previous Employer:Job Title:Dates of Employment:Are you still working there?YesNoDates of Termination:Reason for Leaving:DBS & Children’s Workforce ChecksEnhanced DBS:YesNoUpdate Service:YesNoWilling to complete Children’s Workforce Health Questionnaire:YesNoWilling to complete mandatory safeguarding training:YesNoAvailabilityTick all that apply:Full‑timePart‑timeBankWeekendsNightsReferencesReference 1Full Name:Role/Position:Organisation:Contact Number:Supporting StatementExplain why you want to work in adult social care:Upload Training CertificatesUpload any relevant certificates:Safeguarding trainingChoose FileNo file chosenDelete uploaded fileFirst AidChoose FileNo file chosenDelete uploaded fileMedicationChoose FileNo file chosenDelete uploaded fileCare CertificateChoose FileNo file chosenDelete uploaded fileAny other relevant certificatesDrag and Drop (or) Choose FilesHealthcare Declaration & QuestionnaireGP DetailsGP NameGP PracticeGP Email AddressGP Phone NumberGeneral Health DeclarationTick all that apply:I am in good physical healthI am in good mental healthI am fit to work with children aged 0–18I can carry out lone workingI can carry out physical dutiesIf you have any health conditions that may affect your role, please provide details:Medical ConditionsTick any that apply:AsthmaDiabetesEpilepsyHeart conditionsAllergiesMental health conditionsOtherDescribe how this is managed:MedicationDo you take regular medication?YesNoList medication if applicable:Immunisation Status (Adult Workforce)Tick any that apply:TetanusMMRHepatitis BCOVID‑19OtherProvide details if applicable:Work‑Related Health ConsiderationsTick any that apply:Previously signed off workPreviously had adjustmentsMay require adjustmentsProvide details if applicable:DeclarationConsent *I confirm the information provided is accurate and complete. I understand that providing false information may result in withdrawal of employment.Submit Application
