Application Form
We are committed to safeguarding and promoting the welfare of children. All applicants must complete safer recruitment process, including checks with past employers and an enhanced level DBS. All applicants must answer ALL questions with no omissions. Failure to disclose information may result in an offer of employment being withdrawn. We are an equal opportunities employer.
Position Applied for
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Registered Manager
Deputy Manager
Senior Residential Support Worker
Residential Support Worker
Therapist
How did you hear about this role?
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Indeed
Linkedin
Panacea Website
Employee referral
Word of Mouth / Friend
MAIC Agency - Recruitment agency
Shire-HCS - Recruitment agency
Award Employment- Recruitment Agency
Facebook
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Personal
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Mr.
Mrs
Ms
Miss
Mx
Other
Prefix
First Name
Surname
Have you ever been known by a different name or title?
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Yes
No
If yes, please provide your previous name or put n/a
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Email
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example@example.com
Home Phone Number
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Area Code
Phone Number
Mobile Number
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Date of Birth
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Day
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Month
Year
Date
National Insurance Number
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Address
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Street Address
Street Address Line 2
City/ County
Postal
Move in Date
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Day
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Month
Year
Date
Have you lived at the same address for the last 5 years?
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Yes
No (please provide previous address(es)
If you have lived at your current address for less than 5 years, please provide a 5 year address history including dates
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Do you have any relationships with employees?
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Yes
No
Will this be your only employment if successful?
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Yes
No
Do you have the right to work in the UK?
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Yes, permanent
Yes, temporary
No
In the last 10 years, have you spent more than 3 months abroad at any one time?
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Yes
No
Are you qualified for the role?
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Yes
No
Qualification
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Unqualified
Working toward relevant qualification
Level 3 Health & Social Care
Level 4 Health & Social Care
Level 5 Leadership & Management
Level 7 Management
Safer Recruitment Questions
Panacea Children's Home is mandated to conduct safer recruitment checks for all candidates. This includes confirming candidates enhanced DBS, proof of ID, proof of address, gaps in employment, reasons for leaving previous employment. Please confirmt
Yes
No
Have you ever been subject to any investigation, fact findings, disciplinary action or dismissed from paid, unpaid, voluntary, other employment, training or other programme with children, young people and/or vulnerable adults that was either substantiated or unsubstantiated?
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Yes - Please provide details below
No
Have you ever had any disciplinary action against your name? Depending on the reason for the warning, we may have to write to the relevant company to confirm the action that was taken.
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Yes - Please provide details below
No
Have you ever been dismissed or resigned after disciplinary procedures have been instigated?
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Yes - Please provide details below
No
Have you ever had any safeguarding concerns raised against your name include anything that resulted in no further action made?
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Yes - Please provide details below
No
Do you have any medical conditions or illness that may impact on your ability to care for children and young people including if required to use physical intervention if this was need to protect a child or young person from harm?
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Yes - Please provide details below
No
Is there any other information that you would like to disclose or discuss?
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Yes - Please provide details below
No
Provide details here
DBS and Criminal Information
This position is exempt from the Rehabilitation of Offenders Act 1974. Applicants are required to disclose all convictions and cautions, including those that are spent, unless they are considered protected under the Exceptions Order 1975 (as amended). A DBS check will be conducted
Do you have any criminal convictions or cautions against your name? Please detail all convictions/cautions, including the dates
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Yes - Please provide details in Disclosure Information
No
Have you ever received a Caution, Reprimand or Warning?
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Yes - Please provide details in Disclosure Information
No
Are there any alleged offences outstanding against you?
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Yes - Please provide details in Disclosure Information
No
Do you currently have a valid DBS on the update service?
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Yes
No
Disqualification from Working in Children’s Social Care
The post for which you are applying is covered by the Disqualification from Caring for Children (England) Regulations 2002 and Disqualification from Caring for Children(Wales) Regulations 2004. You are therefore required to complete this form before you can be considered for this post.
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Yes
No
Has a child of yours, at any time, been the subject of a care
order?
2. Has an order been made at any time for the purpose of
removing a child from your care or preventing a child living with
you?
3. Have you ever been connected to a voluntary or registered
home which has been removed from the register?
4.Has an application made by you for registration of a
voluntary or registered home ever been refused?
5. Have you ever been prohibited from being a private foster
parent?
6. Have you ever been refused registration to be a child minder
or provider of day
Please answer the questions below. If you are unsure about these questions, please refer to the Regulations named above and if you think you are registered as disqualified or you are connected to someone in your household that may be disqualified. If you would like to know the criteria for disqualification, you can talk in confidence to Ofsted on 0300 123 1231 or visit www.ofsted.gov.uk.
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Rows
Yes
No
1. Have you ever been disqualified from working in children’s social care?
2. Do you live in the same household as another person who is disqualified?
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Employment & Reference Information
We must have full employment history for all roles paid, unpaid or any other type of role since the age of 16 years old. We reserve the right to request information from any caring role as part of safer recruitment checks. Please provide details of all roles since leaving school. Failure to disclose information may disqualify your application or result in dismissal without notice.
Are you currently employed?
Yes
No
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Current Role
Job role
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Name of Employer
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Address of Employer
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Start date of employment
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Day
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Month
Year
Date
End date of employment
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Day
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Month
Year
Date
Reason for leaving
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Referee Name
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Referee Position
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Relationship to Referee
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Referee Email
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Referee Contact Number
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How many past jobs would you like to list?
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Please Select
1
2
3
4
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Previous Job 1
Job role
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Name of Employer
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Address of Employer
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Start date of employment
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Day
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Month
Year
Date
End date of employment
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Day
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Month
Year
Date
Reason for leaving
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Referee Name
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Referee Position
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Relationship to Referee
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Referee Email
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Referee Contact Number
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Previous Job 2
Job role
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Name of Employer
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Address of Employer
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Start date of employment
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Day
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Month
Year
Date
End date of employment
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Day
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Month
Year
Date
Reason for leaving
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Referee Name
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Referee Position
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Relationship to Referee
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Referee Email
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Referee Contact Number
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Previous Job 3
Job role
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Name of Employer
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Address of Employer
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Start date of employment
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Day
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Month
Year
Date
End date of employment
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Day
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Month
Year
Date
Reason for leaving
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Referee Name
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Referee Position
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Relationship to Referee
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Referee Email
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Referee Contact Number
*
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Employment Gaps
Have you had any gaps (e.g., longer than 1 month) in your employment history
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Yes
No
Please provide reasons for all gaps in your employment history
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Education
Schools attended since age 11
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College
University
Further Formal Training
Driving Status
Do you hold a full UK Driving Licence?
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Yes- manuel
Yes- automatic
No
Do you have any driving endorsements?
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Yes
No
Supporting Statement
Please explain how you meet the requirements outlined in the Person Specification. You should give examples from previous paid, unpaid employment including any transferable skills you have gained.
Please upload your recent and up to date CV
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Declaration
Panacea Children’s Home is mandated to complete safer recruitment checks for all roles. If you progress, your offer will be subject to satisfactory checks, which may include: Enhanced DBS check (including children’s barred list). Right to work in the UK, proof of identity, and proof of current address.Full employment history, with explanations for any gaps.References, including your most recent employer and any employer where you worked with children or vulnerable adults, confirming reason(s) for leaving. Qualification/training verification and professional registration (where applicable). Overseas criminal record checks and additional references if you have lived or worked outside the UK (typically 3+ months).
I declare that the information given in this form is complete and accurate.
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Yes
I understand that any false information or deliberate omissions will disqualify me from employment or may render me liable to summary dismissal.
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Yes
I agree that, if I am appointed, the information may be used as part of the personnel record of my engagement under GDPR regulations.
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Yes
I agree to for the company to access relevant details as part of safer recruitment regarding any points, convictions or cautions from the DVLA.
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Yes
I understand that if I give false information or withhold relevant information it could result, in termination of employment.
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Yes
Signature
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Full Name
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Date of Signature
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