Time2Care (BSE) Ltd Application Form

Medical Information
NHS Number
GP Name
Name of surgery
GP Surgery Address

Street Address

Street Address Line 2

TownCounty

Post Code
Do you have any health conditions to declare?*

Yes, but will not affect the role of a Community CarerYes, may require reasonable adjustments for the role of a Community CarerNo
If you answered yes to the above question, is your health condition connected to:

Physical HealthMental HealthBoth

Employment History
Have you previously worked within the Care Sector?*

YesNo
If you answered yes to the above question please type the month and year you last worked within the care sector.
Name and Address of most recent employer*
Job Title*
Date started work for the above employer*

DayMonthYear
Date
Date left this employment

DayMonthYear
Date
Are you still working for the above named Employer?

YesNo
Reason for leaving this position
Name and address of employer prior to the one above
Job title
Date started work for the above employer

DayMonthYear
Date
Date left this employment

DayMonthYear
Date
Reason for leaving this position

Carer Standards

In order to guide the interview process, we would like you to indicate your personal philosophy of care by completing the following statements
I believe that the purpose of care from a care service is:*
If I were Service User in the Agency I would like:*
I believe that the Service User’s family and relatives would like from the Agency:*
I believe that I can support a Service User in the Agency because: *
As a member of the Agency care team I feel valued when:*
I believe that a good relationship between me and the Service User depends on:*
I believe that I learn best when: *
I believe that a good working team is made by: *
I believe that my role in relation to the Service User is:*
My other beliefs and values of relevance to my job are:*

Medical Information