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

    Key information document

    This document sets out the key information about your relationship with us, should your application be successful, including details about pay, holiday entitlement and other benefits.

    Further information can be found on our website, by following this link: Cheriton Homecare.

    The Employment Agency Standards (EAS) Inspectorate is the government authority responsible for the enforcement of certain agency workers rights.

    You can raise a concern with them directly or through Acas helpline.

    Your name (please fill out this field):
    Your email (please fill out this field):
    Name of Employment Business: Cheriton Homecare Limited
    Your employer(if different from the employment business):Self Employed
    Type of contract you will be engaged under: Contract for Services
    Who will be responsible for paying you (if different from the employment business): N/A
    How often will you be paid?: Weekly
    Expected or minimum rate of pay: Minimum of £100 per day / £700 per week
    Deductions from your pay required by law: None
    Any fees for goods or services: None
    Holiday entitlements and pay: None
    Additional benefits: None

    Example Pay

    Example rate of pay: £100 per day
    Deductions required by law: £0
    Any other deductions or costs from your wage: £0
    Any fees for goods or services: £0
    Example net take home pay: £700 per 7 day week

    Application for Registration as a Self Employed Care Assistant

    Personal details

    Passport and work permit details

    Data Barring Service (DBS)

    General Information

    Industry Related 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 2


    Reference 3


    Professional Experience

    Personal Hygiene

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

    Bed bathCare of eyesCare of fingernailsMouth careUse of bath aids


    Applying a conveenAttaching a night bagBedpans / commodesChanging a catheter bag

    Continence careEmptying a catheter bagStoma careOther (please specify below)

    Care Duties

    Assisting with medicationPressure area carePhysical restraint skills

    Simple dressing proceduresPalliative careOther (please specify below)


    FeedingPreparing meals

    Food handlingOther (please specify below)


    Moving and handling clientsUse of hoists

    Use of walking aidsOther (please specify below)

    Practical Tasks

    BedmakingCollecting benefitsLight housework

    Recording temperatureShoppingOther (please specify below)

    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)




    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?


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



    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.