Recruitment – Wellspring Care Services

Please complete all sections of this form in block capitals. This information will be stored on the HR Database and Payroll System if applicable.

Please note that if at any time during your employment with Wellspring, the information provided below changes, it is your responsibility to inform the HR Department.

- Step 1 of 8

Personal Information

Position Applied For *

Title

Name *

First

Last

Phone Number

Mobile Number *

example +447879090909

Email *

Confirm Email

Please enter your email, so we can follow up with you.

Address *

City *

County

Post Code *

Date of Birth *

N.I. Number *

Passport Number

Nationality *

Visa/Biometric Card Number

Marital Status

Professional Registration Details

Name of Professional Body

Membership Grade and/or Registration and Pin Number

Professional Registration Expiry Date

Driving Details

Do you currently possess a UK Driver’s Licence? *

Driving licence number

Do you have any unspent points on your licence? If so, please give details below *

Non-EU National

Do you need to obtain a work permit to take up employment in the UK? *

Do you have a Work Permit? If yes, answer the following questions *

When is your Work Permit valid from?

When is your Work Permit valid to?

What is your Work Permit Number?

Educational History

Institution Attended 1

Start Date

End Date

Qualification

Institution Attended 2

Start Date

End Date

Qualification

Institution Attended 3

Start Date

End Date

Qualification

TRAINING AND DEVELOPMENT

Please use the space below to give details of any training or non-qualification-based development which is relevant to the post and supports your application.

Training Course 1

Course Details (Nature of Training)

Training Course Length

Training Course 2

Course Details (Nature of Training)

Training Course Length

Training Course 3

Course Details (Nature of Training)

Training Course Length

HEALTHCARE ASSISTANTS/SUPPORT WORKERS: CLINICAL DETAILS

Clinical Area

Length of Experience

Adolescent

Length of Experience

Elderly

Adolescent

Learning Disabilities

Adolescent

Nursing Homes

Adolescent

HEALTHCARE ASSISTANTS/SUPPORT WORKERS: FURTHER TRAINING/UPDATES

Level 2 Diploma Health & Social Care *

Date

Level 3 Diploma Health & Social Care *

Date

Manual Handling Theory & Practice *

Date(Manual Handling)

Food Safety *

Date (Food Safety)

Health & Safety *

Date(Health and Safety)

Risk Assessment *

Date Completed(Risk Assessment)

Fire *

Date Completed(Fire Training)

COSHH

Date Complete (COSHH)

Infection Control

Date Completed(Infection Control)

Medication Training

Date Completed(Medication Training)

Epilepsy Awareness *

Date Completed(Epilepsy Awareness)

Safeguarding of Adults at Risk Training (SOAR) *

Date Completed(Safeguarding of Adults at Risk Training)

Safeguarding of Children Training *

Date Completed(Safeguarding of Children Training)

Others

HEALTHCARE ASSISTANTS/SUPPORT WORKERS: SKILLS ASSESSMENT

Continence Care

Use of Hoists

Report Writing

Blood Sugar Testing

AVAILABILITY FOR WORK

Tick where you are available.

Monday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Tuesday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Wednesday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Thursday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Friday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Saturday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

Sunday

Morning 07:00 – 11:00
Afternoon 11:00 – 15:00
Evening 15:00 – 19:00
Late Evening 19:00 – 00:00
Night 00:00 – 07:00

How many hours would you like to work each week?

Minimum hours/week: *

Maximum hours/week: *

Notes: Are there any special circumstances affecting your working hours?

E.g. available alternate weekends, available if given enough notice, etc.

Are you a car driver?

If you intend to use your car for business, do you have the required insurance cover? If yes, you will be required to produce both your driving licence and motor insurance certificates.

EMPLOYMENT HISTORY Previous Employment:

Please include any previous experience (paid or unpaid), starting with the most recent

Current or Most Recent Employment

Current or Most Recent Employer's Name

Current or Most Recent Employer's Address

Position Held at Current or Most Recent Employment

Date Started Most Recent Employment

Date Ended Most Recent Employment

Reason for Leaving Most Recent Employment

Description of Duties at Most Recent Employment

Previous Employment

Previous Employer's Name 1

Previous Employer's Address 1

Position Held at Previous Employment 1

Date Started Previous Employment 1

Date Ended Previous Employment 1

Reason for Leaving Previous Employment 1

Description of Duties at Previous Employment 1

Previous Employer's Name 2

Previous Employer's Address 2

Position Held at Previous Employment 2

Date Started Previous Employment 2

Date Ended Previous Employment 2

Reason for Leaving Previous Employment 2

Description of Duties at Previous Employment 2

Previous Employer's Name 3

Previous Employer's Address 3

Position Held at Previous Employment 3

Date Started Previous Employment 3

Date Ended Previous Employment 3

Reason for Leaving Previous Employment 3

Description of Duties at Previous Employment 3

HEALTH AND ABSENCE RECORD

Please state any periods of absence over the last 12 months and provide the number of days lost and reasons for each of these.

Date of Absence 1

Reason for Absence 1

Date of Absence 2

Reason for Absence 2

Date of Absence 3

Reason for Absence 3

EMERGENCY CONTACT DETAILS

Name of Emergency Contact

Relationship

Address of Emergency Contact

Email of Emergency Contact *

Home Phone/Mobile of Emergency Contact *

Work Phone of Emergency Contact

LANGUAGES

In which languages are you proficient? Please indicate the level of proficiency below 1 - Basic 2 - Working Knowledge 3 - Fluent

Language 1

Spoken - Level of Proficiency

Reading - Level of Proficiency

Writing- Level of Proficiency

Language 2

Spoken Level of Proficiency 2

Reading of Proficiency 2

Writing - Level of Proficiency 2

Language 3

Spoken - Level of Proficiency 3

Reading - Level of Proficiency 3

Writing - Level of Proficiency 3

CRIMINAL DECLARATION

Please complete the following section accurately. Because of the nature of the work for which you are applying this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act 1974 (Exceptions) Order 1975. Applicants are, therefore, not entitled to withhold information about convictions or cautions which for any other purposes are ‘spent’ under the provision of the Act. Failure to disclose these could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions which the Order applies. Any offer made by Wellspring for this position will be subject to satisfactory receipt of an Enhanced/Standard Disclosure certificate from the Criminal Records Bureau.

Do you have any previous convictions/cautions/criminal record?

Have you been disqualified in any way from working, or having contact with or near children? If yes, please give details.

Nature of Offence

Sentence or Court Order(s)

DISCLOSURE AND BARRING SERVICE (DBS) CHECK

Has a DBS check been conducted on you?

DBS Certificate Number:

BANK/BUILDING SOCIETY DETAILS

Account Holder’s Name: *

Bank Name:

Sort Code: *

Account Number *

Authorising WellSpring to Pay to this Account *

I authorise Wellspring to pay my earnings directly into the bank or building society whose details I have given above. I confirm that I will notify Wellspring in writing of any changes of these details.

Date

REFERENCES

Please give the name, address and position of two referees (current and previous employers) from who references may be obtained.

Reference Name: 1 *

Reference 1 Job Title

Referee's Company Name 1:

Referee Address 1:

Referee Email 1 *

Home Tel 1:

Work Tel 1:

Mobile 1:

Reference Name: 2 *

Reference 2 Job Title

Referee's Company Name 2

Referee Address 2

Referee Email 2 *

Referee Phone 2

OTHER INFORMATION

Are you aware of any circumstances or characteristics not covered by your previous answers that might affect your suitability for employment (e.g., addiction to alcohol or illegal use of drugs)? Failure to disclose relevant circumstances may itself be regarded as evidence of unreliability.

Do you have, or have you had, any medical conditions that might affect your performance in undertaking the post being applied for? If yes, please give details below.

Is any member of your family or household employed by this Company? If yes, please state their name and the Department that they work at.

Name

Department

Please state where you heard about the role

Upload your CV please

Click or drag a file to this area to upload.

EQUAL OPPORTUNITIES MONITORING

Wellspring is committed to promoting equal opportunities in employment, training and development. You are invited to complete this section to help us monitor the effectiveness of our Equal Opportunities Policy.

Ethnicity

Asian

Bangladeshi
Chinese
Indian
Pakistani
Any other Asian background

Black

African
Caribbean
Any other Black background

Mixed

White and Black Caribbean
White and Black African
White and Asian
Any other Mixed ethnic background

White

English/Welsh/Scottish/British
Irish
Any other white background

Other Ethnicity

Gender *

Disability

Do you have an illness or condition that is considered a disability as defined by the Disability Discrimination Act? (The Act defines a disability as "a physical or mental impairment that has substantial and long-term adverse effect on the ability to carry out normal day-to-day activities".)

Please describe what assistance would be required to help you in performing this post:

DATA PROTECTION STATEMENT

The information that you provide on this form and on any CV given will be used by Wellspring to provide you work finding services. In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our clients. We may check the information collected with third parties or with other information held by us. We may also use or pass information to certain third parties to prevent or detect crime, to protect public funds, or in other ways permitted or required by law.

Tick to agree to above Data Protection Statement *

I agree

Download and read and sign GDPR form

GDPR Consent *

I have read and agree to the GDPR

Date Agreed to Data Protection Statement

GDPR Agreement *

I have downloaded, read and signed the GDPR Data protection consent.

I declare that the information I have given is true and complete to the best of my knowledge and belief.

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