Fairfield - Application Form

Fairfield Residential Application Form

Please complete the form below to apply for a position with us.
Strictly private and confidential

Before completing the application form, please note the following:
- All questions must be answered.
- Additional sheets of A4 paper can be used if necessary.
- All applicants must complete the application form in full with no gaps in their work/education history. E.g. travelling etc. Curriculum vitae’s cannot be used in place of this application.
- Your application form will not be processed if any information is missing.
Position Applied For*

Residential Support WorkerSenior Support WorkerCommunity Support WorkerTeaching AssistantTeacherEducation Support Worker
Position Type

Full TimePart TimeWaking NightsBank Contract
Full Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Current Address*

CityCounty

Postcode
Email Address*
Phone Number
Are you a UK Citizen?*

YesNo
Are you permitted to work in the UK?*

YesNo
National insurance number*
Do you have a current DBS

Child DBSVulnerable Adults DBSCombined Child & Adult DBS
DBS Certificate Number
DBS Certificate Issued Date

MonthDayYear
Have you subscribed to the Live Update Service?*

YesNo
Have you been in the UK for over 5 years?*

YesNo
Do you hold a full UK Driving Licence?*

YesNo
Do you have a car available for work purposes?*

YesNo
If not, are you willing to get this upon confirmation of post?*

YesNo
Details of any driving convictions in the last ten years
You will be required to escort the children and young person around in your car when on shift. Are you in agreement with this?*

YesNo
Do you have a UK Passport?*

YesNo
From Which Country is your passport issued?
Are you related by family or friendship to any of Fairfield’s governing body or staff? If yes, please give their name:
Have you ever been dismissed from any previous employment on the grounds of safeguarding, misconduct or incapacity? If yes, please give details:
Where did you hear about the post you are applying for:
Have you ever carried out shifts within Fairfield using agency*

YesNo
Previous employment

Please use this section to provide information about your previous employment starting with your current or most recent job.
Previous Positions
Education & Professional Qualifications

(starting with the most current). If short listed, you will be asked to produce evidence of qualifications at the interview (originals, not photocopies). If you hold a nursing qualification please include your p.i.n. Please include any current studies:
Qualification
Voluntary Work
Voluntary Role
References

The first referee must be your present or most recent employer

The second referee should be somebody who has known you for 3 years or more, but should not be somebody from your current place of employment. Please provide all information requested.

Please note: Any jobs that you have been in since leaving senior school that have involved children/adults in a looked after setting you must give reference details for. This is part of our safer recruitment checks.

** MINIMUM OF 2 REFERENCES REQUIRED **
Referees
Health
Are there any health issues we should know about that would impede you completing any of the job role or shift work?

YesNo
How many days absence have you had during the last 12 months and how many occasions was this?

YesNo
Staff Disqualification Declaration

Please answer the questions and sign the declaration below to demonstrate that you are safe to work with children.

If there are any aspects of the declaration that you are not able to meet, you should disclose this immediately to the Manager.

Section 1 – Orders or other restrictions
Have any orders or other determinations related to childcare been made in respect of you?*

YesNo
Have any orders or other determinations related to childcare been made in respect of a child in your care?*

YesNo
Have any orders or other determinations been made which prevents you from being registered in relation to child care, children’s homes or fostering?*

YesNo
Are there any other relevant orders, restrictions or prohibitions in respect of you as set out in Schedule 1 of the Regulations? The Regulations are available from the office or at the link below: http://www.legislation.gov.uk/uksi/2009/1547/contents/made*

YesNo
Are you barred from working with Children (Disclosure and Barring (DBS)?*

YesNo
Are you prohibited from Teaching? *

YesNo
Section 2 – Specified and Statutory Offences

Have you been cautioned (including a reprimand or warning) since 6 April 2007 or have you been convicted of:
Any offence against or involving a child? (A child is a person under the age of 18)?*

YesNo
Any violent* or sexual offence against an adult? * A violent offence in this context is murder, manslaughter, kidnapping, false imprisonment, ABH, GBH.*

YesNo
Do you have any unspent conditional cautions or convictions under the Rehabilitation of Offenders Act 1974?*

YesNo
Do you have any adult cautions (simple or conditional) or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020?*

YesNo
Any offence under the Sexual Offences Act?*

YesNo
Any other relevant offence?*

YesNo
Have you ever been cautioned, reprimanded, given a warning for or convicted of any similar offence in another country?*

YesNo
Section 3 – Disqualification by association?
To the best of your knowledge, is anyone in your household* disqualified from working with children under the Regulations? *Household – includes family, lodgers, house-sharers, household employees. This means does anyone in your household have an Order or Restriction against them as set out in Section 1 or have they been cautioned, reprimanded, given a warning or convicted of any offence in Section 2 which is not ‘spent’ in line with the Rehabilitation of Offenders Act.*

YesNo
Section 4 – Provision of information

If you have answered YES to any of the questions above you should provide the details below in respect of yourself, or where relevant the member of your household. You may supply this information separately, if you so wish, but you must do so without delay.
Date of the order, restriction, conviction, etc.

DayMonthYear
The date of these

DayMonthYear
The relevant court(s) or bod(ies)
You should also provide a copy of the relevant order, caution, conviction etc. In relation to cautions/convictions a DBS Certificate may be provided.

The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account.

Guidance about whether a conviction or caution should be disclosed can be found on the Ministry of Justice website.
Section 5 - Declaration
- I understand my responsibilities to safeguard children and vulnerable adults;
- I understand that I must notify my Manager immediately of anything that affects my suitability including any pending court appearance, cautions, warnings, convictions, orders or other determinations made in respect of me or a member of my household that may render me disqualified from working with children. Failure to notify will be a serious matter considered as gross misconduct under Fairfield’s Disciplinary process and could result in summary dismissal.
Please tick this box to confirm the above*

I confirm
Signature

Powered by Jotform SignClear
Name*

First NameLast Name
Date*

DayMonthYear
Date
Declaration of Criminal Convictions

Due to the specific nature of this post which involves close personal contact with Service Users, it is exempt from the Rehabilitation of Offenders Act. This means that you are required to declare any convictions and/or cautions including any which would otherwise be considered “spent” under that Act. This also includes driving related offences.
I have the following convictions and / or cautions to declare:
Please provide a brief overview of the nature of all convictions and / or cautions declared including justifications as to why you believe these would not be detrimental to your performance in this role ( please use additional paper if required)
-- OR --

I have no convictions and / or cautions to declare
Signature

Powered by Jotform SignClear
Name*

First NameLast Name
Date*

DayMonthYear
Date
Suitability for Position

Please give any additional information in support of your application for the post. Include any relevant interests, activities, or experience and training which did not lead to qualifications.
Equal Opportunities

Fairfield has an equal opportunities policy. In order to monitor whether the policy is succeeding we need to have information from candidates. The information will be treated in the strictest confidence and will only be used for monitoring of the equal opportunities policy. This form will be separated from your application upon receipt and will not be used as part of the selection process.
Gender
Do you have a disability? If yes are you willing to disclose?
Do you require any adjustments to attend an interview?
Do you have any special requirements in order to assist you undertaking your duties?
What is your religious affiliation?
How would you describe your cultural and ethnic origin?
Declaration

Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered.

I hereby certify that:
- 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.
Please tick this box to confirm the above*

I confirm
Signature

Powered by Jotform SignClear
Name*

First NameLast Name
Date*

DayMonthYear
Date
Should be Empty:

Fairfield Residential Application Form

Strictly private and confidential

Previous employment

Health

Declaration of Criminal Convictions

Suitability for Position

Equal Opportunities

Declaration