Live-in Carer Application Form

Looking for satisfying work and being able to work with a diverse range of clients? Apply today.

Carer Application Form

If successful in your application are you able to attend induction and training in Brighton?
YesNo

Current CV (pdf): Attach copy of your current CV (2MB max.).

Current Photo: Attach a recent photo for identification purposes (2MB max.).

Personal details

Title

Surname

Forenames in full

Previous Surnames (optional)

National Insurance Number

Telephone Number

Mobile

Passport and work permit details

Do you have a current passport?
yesno

Do you have a Work Permit/Visa?
yesno

Are you registered as self-employed in the United Kingdom?
yesno

If ‘Yes’ what is your Unique Taxpayer Reference (UTR) Number:

Passport Details: Attach copy of your passport showing details (2MB max.) or complete below

Place of issue:

Passport number:

Date of Issue:

Expiry Date:

Known restriction on use:

Data Barring Service (DBS)

DBS Details: Attach copy of your DBS certificate showing details (2MB max.) or complete below

Do you have a current DBS certificate?
yesno

Do you use the update service?
yesno

What is your certificate number?

What is the date on your certificate (your date of birth)?

General Information

Do you hold a current driving license?
yesno

Is your license valid in the UK?
yesno

Do you have a car available?
yesno

Driving license details: Attach copy of your driving license showing details (2MB max.)

Preferences regarding work

Please specify which types of work you would prefer. You should tick all appropriate boxes.
Positions
Full timePart time

Which areas of work do you wish to exclude?

Do you have any other work commitments?

References

Please give the names, occupation and contact addresses / details of 3 people we can contact for references. One of which must be your current or most recent employer. If you have not been employed please provide the name of a professional person who can comment on your suitability for this position.

Reference 1

Reference contact name

Job title

Do we have your consent to contact your references?

Phone number

Mobile number

Email address

Your job title

Length of employment (including from/to dates)

Responsibilities

Reasons for leaving

Reference 2

Reference contact name

Job title

Do we have your consent to contact your references?

Phone number

Mobile number

Email address

Your job title

Length of employment (including from/to dates)

Responsibilities

Reasons for leaving

Reference 3

Reference contact name

Job title

Do we have your consent to contact your references?

Phone number

Mobile number

Email address

Your job title

Length of employment (including from/to dates)

Responsibilities

Reasons for leaving

Professional Experience

Personal Hygiene

Bath / shower / strip washCare of hairCare of feetDressing / undressing

Other:

Toileting

Applying a conveenAttaching a night bagBedpans / commodesChanging a catheter bag

Continence careEmptying a catheter bagStoma careOther (please specify below)

Other:

Care Duties

Assisting with medicationPressure area carePhysical restraint skills

Simple dressing proceduresPalliative careOther (please specify below)

Other:

Nutrition

FeedingPreparing meals

Food handlingOther (please specify below)

Other:

Mobility

Moving and handling clientsUse of hoists

Use of walking aidsOther (please specify below)

Other:

Practical Tasks

BedmakingCollecting benefitsLight housework

Recording temperatureShoppingOther (please specify below)

Other:

Administrative Abilities

ConfidentiallityObserving/recording changesSign language

Report writingArranging appointmentsRecording instructions from GP

Training Received

Manual handling (adult)

Infection control

Fire safety

First aid

Essential food hygiene

Observational skills

Lone worker

Management of aggressive or violent behaviour

Abuse awareness (POVA)

Abuse awareness (POCA)

Safeguarding Training (Adult)

Health & safety (incl COSHH and RIDDOR)

Basic life support (Adult)

Medication

Other certification

Do you consent to the use and processing by Cheriton Homecare of personal data for the purpose of farthing your application for a position as a self employed care assistant with the company?

yesno

Do you agree to our privacy policy, so that we can contact you about your application?

yesno

Declaration

The information that I have given in this application form is, to the best of my knowledge, complete and accurate in all respects, and I am not aware of any reason why I am not fit for this work. I understand that knowingly giving false information will disqualify me from registration with the agency.

Signature

Date

Name

Position applied for

Location