Therapeutic Support Worker Application Form

Application Form

Therapeutic Support Worker
Post Applied For
Name

First NameLast Name
Previous Names
Have you ever been known by any other name?
Please list all other names you have been known by, and the dates you used them.
Address

Street Address

Street Address Line 2

Town / CityCounty

Postcode
Address History
Current address

Street Address

Street Address Line 2
Town / CityCountyPostcode
Date you moved to this address

DayMonthYear
Date
Have you lived at this address for 5 years or more?

Home Number
Mobile Number
Email
example@example.com
Date of birth

DayMonthYear
Date
National Insurance number
Are you free to remain and take up employment in the UK with no current immigration restrictions?

Other
Can we contact you at work?

Rows	Full address including postcode
Address
Date from
Date to

Since leaving school, have you lived, worked or studied outside the UK for more than three continuous months?
Employment and Activity History

For a children’s residential care job application.
Applicants must provide a full employment history from leaving school to the present, with every month accounted for and no gaps.
Are there any gaps between the dates listed above, including periods of unemployment, education, travelling, caring responsibilities or living overseas?
Employment Gaps Configurable List
Employment History
Have you ever been involved in any disciplinary or grievance proceedings?
If yes, please identify the employer and briefly explain the matter and outcome.
I confirm that this history is complete and accurate.
Education

Qualifications obtained from Schools, Colleges and Universities. Please list highest qualification first:
Overseas History

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date (MM/YY)

Rows	Education
Education Provision
Course
Qualifications and grades obtained
Date

Training and Development

Please give details of any training and development courses or non-qualification courses that support your application. Include any on-the-job training as well as formal courses.

Personal Statement

Abilities, skills, knowledge and experience.
Please use this section to explain in detail how you meet the requirements within the competencies stated in the Job Description. If you are or have been involved in voluntary/unpaid activities, please also include this information.

Rehabilitation of Offenders Act (1974)
Do you have any convictions that are unspent under the Rehabilitation of Offenders Act 1974?
If yes, please give details / dates of offence(s) and sentence:

Disability Discrimination Act:

This Act protects people with disabilities from unlawful discrimination. Ubuntu Group Ltd actively encourage applications from people with disabilities. The Disability Discrimination Act defines a disabled person as someone who has a physical or mental impairment which would impact on his or her ability to carry out normal day to day activities.
We will try to provide access, equipment or other practical support to ensure that people with disabilities can compete on equal terms with non-disabled people.
Do you have a disability that is relevant to your application?
If yes, please give details:
Do we need to make any specific arrangements for you to attend the interview?
If yes, please give details:
Health
Number of days' sickness absence in the last 2 years:

Protecting Children

All posts advertised by Ubuntu Group Ltd will be subject to an enhanced DBS check.
Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?

Rows	Reference 1 (must be current/most recent employer)
Full Name
Position (Job Title)
Work Relationship
Organisation
Full Address
Phone Number
Email Address (MUST BE FROM A WORK EMAIL, NOT PERSONAL)
Are you willing for this referee to be approached prior to the interview?

Rows	Reference 2
Full Name
Position (Job Title)
Work Relationship
Organisation
Full Address
Phone Number
Email Address (MUST BE A WORK EMAIL, NOT PERSONAL)
Are you willing for this referee to be approached prior to the interview?

Disclaimer Form

The Disqualification for Caring for Children Regulations 2002 applies to anyone employed in a registered or voluntary children’s home. The Regulations set out grounds for disqualification from caring for children. These fall into three main areas: 1. Where a child of the individual has at any time been the subject of a care or similar order, or where an order has been made with the purpose of removing a child from the individual’s care or preventing the child from living with him/her. 2. Where the person has been convicted of an offence specified in Schedule 1 of The Children and Young Persons Act or one involving injury or threat of injury to another person. 3. Where: The person has been concerned with a voluntary or registered children’s home which has been removed from the register; or An application by the person for registration of a voluntary or registered children’s home has been refused; or The person has been prohibited from being a private foster parent, or the person has been refused registration to be a child minder or provider of day care, or had his/her registration cancelled. I have read and understood the above and declare that I am not disqualified from caring for children under The Disqualification for Caring for Children’s Regulations 2002.
Name

First NameLast Name
Signature
Date

DayMonthYear
Date

Declaration

I confirm that the information given on this application is complete and accurate, and that every month since leaving school has been accounted for.
All the information given by me on this form is correct to the best of my knowledge. All questions relating to me have been accurately and fully answered. I possess all the qualifications which I claim to hold. I have read and, if appointed, am prepared to accept the conditions set out in the conditions of employment and the job description.
Name

First NameLast Name
Signature
Date

MonthDayYear
Date

Application Form