Shared Lives

Carer Application Form

First name
Surname
Date of Birth
Current Address
How Long at Current Address
Home Telephone Number
Work Telephone Number
Mobile Number
E mail address

Other Members of your Household

Name / Date of Birth / Relationship to Applicant / Occupation

What support would you like to provide

What Support would you like to offer (please tick all that are appropriate)
Day Care / Respite / Long Term
What Service User Group would you like to Support? (please tick all that are appropriate)
Older People / Mental Health
Learning Disabilities / Physical Disabilities
What age groups would you like to support / 18-24 / 25-39 / 40-65 / 65+

Employment

Please give details of all previous jobs since leaving full time education. Full details should be given for any period not accounted for by full time employment, education or training (e.g. unemployment, voluntary work, raising a family, part time work). Enclose additional sheets if necessary.

Employer / Job held and brief details / Reasons for leaving / FromTo

Qualifications & Training

Please give details of any qualifications and training courses undertaken which are relevant to the job together with dates. Continue on a separate sheet if necessary.

Qualifications & training
Show grades and institutions where obtained / From / To
Suitability for the scheme
Please state why you think you are suitable for the Shared Lives Scheme, include any relevant work experience. Continue on separate sheets if necessary:

References

Employer Reference
Please give the name, address and telephone number, email address of your current or most recent employer
Personal References
Please give details of two people whom you have known for more than 2 years.
Please note that relatives or partners cannot act as personal referees
Personal Reference 1 / Personal Reference 2
Name
Address
Telephone
Email
Length of time known and in what capacity

Consent and Agreements

I declare I have no criminal convictions (even those that are deemed to be spent)
OR (delete as applicable)
I have criminal convictions that I am willing to discuss
I declare I know of no conflicts of interest relevant to my application as Shared Lives carer
OR (delete as applicable)
I am aware of conflicts of interest that I am willing to discuss
I consent for detailed checks and references to be taken up to support my application to become an Shared Lives carer. I understand that these checks could involve information about myself of a confidential and personal nature.
I consent for information about me to be kept by the Shared Lives Scheme both in paper and on a computer database. The information will be used in documents relevant to the service you are providing.
I consent to information about me being passed by the service to the regulatory body as required
I am eligible to work in the UK and my NI number is:
I confirm I am willing to carry out personal care support to individuals in my care
I confirm that I have not been dismissed or been subject to any disciplinary procedures as a carer from a Shared Lives Scheme, Fostering /Adoption Service or any other CQC Registered Service.
Signature of Applicant / Date

Personal Profile

Please outline below a profile of you as a person. If you find it difficult to write about yourself, maybe outline how you think your friend and family would describe you.

This exercise is designed to give a picture to the Shared Lives worker and independent panel of the sort of person you are and what makes you tick. This is important if you are to share your life and household with a disabled or vulnerable person as a Shared Lives Carer.

Strengths
Weaknesses
Likes
Dislikes
Dreams
Fears
Hobbies & Interests
What Motivates you
Personality Traits
You and Your Family
Pets
Any languages/skills etc
Anything else you wish to add

Health Declaration

Full Name…………………………………………………… Date of Birth …………………..

Address……………………………………………………

……………………………………………………

……………………………………………………

As an Approved Self Employed Carer for the Shared Lives Scheme it is important that you are physically and emotionally able to carry out your duties safely and effectively.

In order for the Shared Lives Scheme to ensure correct and successful matches are made and that the correct support is given to both the Approved Carers and Individuals accessing the service, we require all potential and Approved Carers to complete a declaration regarding their health. This will maintain the safety of all individuals concerned.

Please complete all sections below giving as much detailed information as possible (continue on a separate sheet if this is needed)

Current Medical Conditions
Current Medication
Any other information

If the Shared Lives Scheme has any concerns regarding the information provided it may be necessary to contact your GP for further information.

Please complete your GP details and sign to confirm your consent.

GP Name………………………………………………………………………………..

Surgery Name………………………………………………………………………………..

Surgery Address………………………………………………………………………………..

………………………………………………………………………………..

………………………………………………………………………………..

Signature of Consent ……………………………………………………………………….

It’s your responsibility to ensure that the information is accurate and a true reflection of your current health. Failure to disclose any significant health issues may result in your application to become an Approved Carer being declined or your registration being withdrawn.

If there are any changes to your health that impacts your ability to carry out your duties you must contact the Shared Lives Scheme as soon as possible.

Signature………………………………………………………………………………..

Date………………………………………………………………………………..

Checked (office)

Signature………………………………………………………………………………..

Date………………………………………………………………………………..

Further action needed Yes/No

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