Care Sector Agency Worker Registration Form

Personal Details
Full name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
Date
National Insurance number
Gender
Emergency contact name

First NameMiddle NameLast Name
Emergency contact relationship
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact email
Emergency contact notes
Contact Details
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Address History
Current address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous address history
Role Applied For
Care role(s) applied for

Other
Preferred care settings

Other
Job preferences
Availability, Location and Travel
Availability Type

Other
Preferred Work Location
Preferred Travel Radius (miles)
Transport Access

Other
Right to Work in the UK
What is your current right-to-work status in the UK?

Other
Share code (if applicable)
Visa or immigration status
Visa or permit expiry date

MonthDayYear
Date
Upload proof of identity

Cancelof
DBS and Safeguarding
DBS status
Are you subscribed to the DBS Update Service?
DBS certificate number
DBS issue date

MonthDayYear
Date
Upload DBS certificate or disclosure document

Cancelof
Criminal convictions or declarations relevant to safer recruitment
Safeguarding declaration
Professional Registrations, Qualifications and Training
Do you hold any professional registration?
Registration details
Upload qualifications and certificates

Cancelof
Mandatory training completed
Employment History and Experience
CV upload

Cancelof
Explanation of any gaps in employment
Care experience and relevant duties
Professional references
Permission to contact references
Occupational Health and Fitness to Work
Fitness to work outcome
Recommended adjustments or restrictions
OH reviewer name
OH review date

MonthDayYear
Date
OH internal notes
Immunisation or vaccination status relevant to work

Other
Recent infectious disease exposure

Other
Do you have any current health condition that may affect your ability to work safely?
Which of the following health areas apply to you?

Other
Please provide details of any health condition or concern that may affect work safety
Do you have any allergies we should know about?

Other
Please provide allergy details and any required precautions
Do you have any back problems or musculoskeletal conditions that may affect manual handling or lifting?
Do you have any mobility limitations that may affect your duties?
Do you have any mental health condition that may affect your work or support needs?
Please describe any medication you take that may affect safe working
Are you currently pregnant or a new or expectant parent and would like any risk considerations to be reviewed?
Do you have a disability or long-term health condition?
Please tell us about any reasonable adjustments you would like us to consider
Do you consent to an occupational health referral if required?
Do you consent to share only your fitness-to-work outcome with the recruitment company and relevant care clients?
In an emergency, do you consent to appropriate medical treatment being arranged if you are unable to give consent?
Bank/Payroll Details
Secure payroll information (confidential)
Account holder name
Bank name
Account number
Working Time Regulations acknowledgement
Terms, Privacy and Declarations
GDPR and privacy notice acknowledgement

Other
Consent to process and share information for recruitment and work-finding purposes

Other
Consent to verify documents, training, DBS, references and employment history

Other
Confidentiality agreement

Other
Conduct, complaints and whistleblowing acknowledgements

Other
Declaration
E-signature
110% Care People

Better People. Better Results. Always.
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Personal Details

Contact Details

Address History

Role Applied For

Availability, Location and Travel

Right to Work in the UK

DBS and Safeguarding

Professional Registrations, Qualifications and Training

Employment History and Experience

Occupational Health and Fitness to Work

Bank/Payroll Details

Terms, Privacy and Declarations

110% Care People