Application form HCA

Full name *

First NameMiddle NameLast Name

Maiden name if applicable

First NameLast Name

Have you been known by any other name is so please complete

First NameLast Name

Date of Birth*

Date

Marital Status*

MarriedSingleDivorcedOther

Nationality *

Address*

Street Address

Street Address Line 2

City

Post Code

Contact Mobile Number *

Area CodePhone Number

Contact Landline phone number *

Area CodePhone Number

National Insurance Number*

Email address:*

Where did you hear about April?

Are you registered with Social Care Wales?*

YesNo

If you are registered with Social Care Wales please provide your registration number

AWIF Qualification Social Care Wales*

Yes I have completed this qualificationI have started the qualification but it is not completedNo I have not started this qualification but I am registered with Social Care WalesNo, I have not registered to complete this qualification

Have you ever had any restrictions placed on your practice or have received any disciplinary action in your previous roles?*

YesNo

If you answered Yes to the above question please provide full details

Have you ever been investigated by Social Care Wales*

YesNo

If you answered Yes to the above question please provide full details

Do you speak Welsh?

YesNo

If you answered yes, what level are you at speaking Welsh? eg fluent, school level etc.

Do you hold a full clean driving Licence*

YesNo

Do you have regular access to transport?*

YesNoOther

If you answered other please clarify

Do you have access to public transport*

YesNo

How far are you prepared to travel to placements *

How many days absence have you had in the last 12 months? *

What was the reason for this time off work? *

This section is to be completed by EEC Nationals only: Date of Entry into the UK

Date

This section to be completed by EEC Nationals ONLY Do you require a valid work permit?

YesNo

If you answered ' Yes ' to the above question please state what documentation you hold and what is the expiry date

If you replied ' No ' to the above question please clarify

Do you have an Enhanced DBS Check*

YesNo

If yes what is the DBS certificate number

Date of issue

Date

Is your DBS Check registered on the update service?*

YesNoNot sure

Portable DBS Reference number if registered on the update service.

Rehabilitation of Offenders Act 1974: By virtue of The Rehabilitation of Offenders Act 1974 ( Exemptions) (amendments) order 1986, the provisions of Section 4.2 of The Rehabilitation Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such kind as to enable the holder to have access to persons in receipt of such services in the course of normal duties. Your answer to the following questions should include any ' spent ' convictions. Failure to disclose any convictions will result in the immediate removal from April Complete Care Solutions register.*

Have you ever been convicted of a criminial offence? YESHave you ever been convicted of a criminal offence? NO

If you have answered Yes please provide full details including dates.

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

YesNo

Are you aware of any current or pending investigations, police enquiries or legal proceedings being undertaken following allegations made by you?*

YesNo

Next of Kin please provide address telephone number and email if applicable Please note these will only be used in an Emergency Situation*

Have you previously worked for April?

YesNo

Please complete Education and further Education details Please add start and end date of school / college FULL DETAILS MUST BE PROVIDED *

Please provide all qualifications and grades obtained *

Please out line any courses you may have recently undertaken that are relevent to this role.

Please provide your full employment history. Please include name of company start and end dates FULL DATES AND EMPLOYMENT MUST BE GIVEN *

Describe your skills and attributes which you feel would be appropriate for this post*

Please provide details of two persons who are willing to supply you with professional references, one of which must be your present or last employer, please do not use personal friends or family. We require Name, What relationship they have with you eg Mum partner etc. Telephone Number, Email Address, Address, Job title of referee.*

Please be aware that if you are offered a position with April Complete Care Solutions, you will be working with vulnerable people, and therefore these references with the referee's permission, can be passed on to a third party at their request. The third party concerned would be limited to April Complete Care Solutions clients.

How did you hear about April Complete Care Solutions?*

Work requirements / preferences: please specify*

Any comments regarding working hours / preference for availability

Equal Opportunities Policy: April Complete Care Solutions operate an equal opportunity policy. In order to help us monitor this policy you are requested to complete this form with your application form. A statement of our equal opportunities policy is included in the recruitment pack. This information is kept on file and is held separately from the information used in the selection process. Ethnic Category: The following categories are based on those used in the 2001 census as recommended by the CRE. Please note the ethnic questions are not about nationality, place of birth or citizenship. UK citizens can belong to any of the ethnic categories indicated. Please tick the box below which best describes the ethnic category to which you belong:*

White BritishWhite IrishOther

If you answered other please complete*

Mixed

White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed background

If you answered any other mixed background please complete

Asian or Asian British

IndianPakistaniBangladeshiAny other Asian background

If you answered Any other Asian background please complete

Black or Black British

Black CaribbeanBlack AfricanAny other Black background

If you answered any other Black background please complete

Chinese or Chinese British or other ethnic group

ChineseAny other ethnic background

If you answered Any other ethnic background please complete

Gender *

If you prefer to use your own identity please complete.

Is the gender you identify with the same as the gender you were registered at birth?*

YesNoRather not say

What is your religion?*

If you have selected other or you would like to state your religion please complete.

What is your sexual orientation*

If you have selected other or prefer to use your own identity please complete

NB

April is committed to the principles of the Modern Slavery Act 2015 and the abolition of modern slavery and human trafficking. As an equal opportunities' employer, we are committed to creating and ensuring a non-discriminatory and respectful working environment for our staff. We want all our staff to feel confident that they can expose wrongdoing without any risk to themselves.

Our recruitment and people management processes are designed to ensure that all prospective employees are legally entitled to work in the UK and to safeguard employees from any abuse or coercion.

Disability (Advice can be obtained from the Disability Rights Commission Telepone: 08457 622633 Please indicate Yes or No to all questions *

	Yes	No
Do you have a physical /mental impairment e.g. hearing or schizophrenia?
Is the adverse effect of the impairment substantial e.g. uses hearing aid or medication?
Is the impairment long-term e.g. has lasted / likely to last for at least 12 months or for the rest of the persons life?
Does the impairment adversely affect your ability to carry out normal day- to-day activities e.g. walking, lifting, speech, hearing, sight?

Please be aware if you answer YES to any of the above disability questions, this means you have a disability even if you are not registered as disabled.

GDPR Statement

All of the information collected in this form is necessary and relevant to the performance of the job applied for. The Company will treat all personal information with the utmost confidentiality and in line with current data protection legislation.

Should you be successful in your application, the information provided, and further information which will be gathered at the relevant time, will be subsequently used for the administration of your employment and in relation to any legal challenge which may be made regarding our recruitment practices.

This agreement is between April Complete Care Solutions limited and

Name*

First NameMiddle NameLast Name

Agreement in respect of the disclosure of confidential information to the staff member.

(1) the staff member shall not use or divulge or communicate to any persons any personal/confidential information and will treat such information as private and confidential and safeguard it according to GDPR indefinitely.

The Data Protection Act 2018 is the UK's implementation of the General Data Protection Regulation (GDPR).

(2) the staff member acknowledges that any breach of confidentiality may result in instant dismissal for gross misconduct and legal action being taken against them.

Signature confirming agreement of above contract*

Date*

Date

Working time directive

The new regulations enforcing the EU working time directive are designed to promote Health & Safety. Under the new legislation a maximum average working week consists of 48 hours over a seven-day period normally worked over a period of 17 weeks.

Any worker can agree to work over 48 hours provided that the agreement is in writing. The worker can at any time end this agreement to work extra hours.

Please confirm below which statement is relevant to you.

Please indicate which statement is relevant to you.*

Yes I am happy to work more than 48 hoursNo, I am not happy to work more than 48 hoursI can not work more than 48 hours for other reasons

Signature*

In the event that the company funds any training should I choose not to continue with my application or if I leave employment within 6 months of the aforementioned training date, I will be required to reimburse the company for all training and associated costs.

Signature*

Date please complete on date of signature*

Date

Application form HCA/ Support worker

April Complete Care Solutions