Employee Form

Employee Form
Name*

PrefixFirstMiddle NameLast
Date of Birth*

DayMonthYear
Email*
Phone Number*
Residential Address*

Street Address

Street Address Line 2

CityState

Post Code
Emergency Contact*

FirstLast
Relationship*
Phone Number*
Regulatory Requirements

NERPSA is required to run the early childhood service in accordance with the provisions of the Children’s Services Regulations 2009 and the Children’s Services Act 1996. Both the Act and the Regulations require, amongst other things, that the staff provide an active, adequate and efficient centre. We have designed the following questions to assist us to meet our responsibilities under the regulations.

Medical Conditions

You are requested to disclose all pre existing injuries and diseases suffered by you which:
- COULD be affected by the nature of your proposed job; or
- Will require NERPSA to make special allowances for or provide additional facilities or equipment to assist you.
PLEASE NOTE - if you
- Fail to disclose this information; or
- Make a false or misleading disclosure,
Section 82 (8) of the Accident Compensation Act 1985 will apply. This means that you will not be entitled to Workers Compensation for any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre existing injury or disease (if it is sustained in the course of or due to the nature of your employment with the preschool).

You are not obliged to divulge questions relating to medical conditions which do not fall into the above categories. However, your overall health management may be assisted if you do as it will provide NERPSA with a more complete picture of your health status. This information will be treated as confidential.

The only time any information will be used is when it is relevant to your capacity to carry out your employment duties. It will only be revealed to those people who need to know in the interests of your health and safety (or the health and
safety of fellow Employees).
Are you aware of any medical conditions such as a preexisting injury or disease, which may affect your ability to perform any of the duties of this position? (Please read your position description before completing this section).*
If yes, please complete and provide details of any pre-existing medical conditions, injury or illness, and state duties which may be affected.
Please advise of any additional services or facilities that could enable you to perform the duties of this position.
Privacy Statement
NERPSA’s Privacy Statement outlines how the personal information, including health information you provide by completing this application, will be used and managed.
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Resume`QualificationWorking With Children CheckPolice CheckFirst Aid CertificateAnaphylaxis CertificateProtecting Children - Mandatory Reporting CertificateOther
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