APPLICATION FORM
NAME:
PRIVATE AND CONFIDENTIAL
Please complete in BLOCK CAPITALS
POSITION APPLIED FOR / Length of experience required? / Home Address & Contact Number / Age & Date of Birth / How do you plan to get to the sanctuary?EDUCATION / Name of Institution
(School, College, University)
From / To
EMPLOYMENT / Name / Address of Employer / Job Title and Main Duties / Dates Start / Leave
Present Employer and any previous jobs / work placements
REFERENCES / Names and addresses of two referees / Can they be contacted now?
Name:
Address:
Contact Number: / YES / NO
Have you ever been convicted of a criminal offence?
If ‘YES’ please give details in the notes section (under the Rehabilitation of Offenders act 1974, spent convictions need not be declared) / YES / NO
AVAILABILITY / Please give details
When would you be available for interview?
Please give requested dates of placement
(Minimum 2 weeks, Maximum 12 weeks)
NOTES / Use this section for any additional information
DECLARATION / Please read carefully, then sign and date your application
I understand that misrepresentation, falsification or omission of information requested on this application form may be cause for the work experience to be terminated. I consent to the company recording my data and disclosing information contained on this form to third parties. I also consent to the company contacting my present and / or previous employer for a reference. I understand that this is not a contract of employment or of apprenticeship and that if I am engaged I will not assume statutory employment rights.
APPLICANTS SIGNATURE: / DATE:
MEDICAL FORM
PRIVATE AND CONFIDENTIAL
Please complete in BLOCK CAPITALS
PERSONAL DETAILS
First Name: / Surname:Address:
Home Tel: / Mobile Tel:
Email:
IMMUNISATIONS
Do you have an up to date Tetanus? YES NO
(Please note that it is strongly recommend that all students have an up to date Tetanus)
MEDICAL HISTORY
We would appreciate if all volunteers could provide us with the following information. This form is confidential and the details will not be disclosed without consent. However, if you do have a medical history which we should know about in the event of incident, it would help if you gave us the name and contact number of your doctor.
If the answer to any of these questions is yes, please use the space provided to explain.
Do you have any allergies? YES NO
Do you have any serious medical condition? YES NO
Are you in any way restricted from physical work? YES NO
Are you currently receiving any medication? YES NO
Are you or could you be Pregnant? YES NO
Do you have a pacemaker, diabetic pump, or similar? YES NO
Please use the space below to give us any further information that you think may be relevant. Thank you.NEXT OF KIN
In the event of an accident/emergency, who should we contact:-
Name / Relation / Home Phone No. / Mobile Phone No.Contact 1
Contact 2
DECLARATION
I ...... declare that to the best of my knowledge, the above information is correct. I do / do not give consent for this to be used in the event of an accident.
Signed...... Date......
If under the age of 18 parent/guardian signature:......