Health Declaration Form

Job Application Form Application for the post of: Highly Specialist Speech and Language Therapist – Hearing Impairment

Accessibility If you require a copy of this application form in another format, please contact [email protected] and provide full details.

Preferred Title (Mr/Mrs/Miss/Ms/Dr/Other)

Surname (family name)

First names (in full)

Home Address

Post code Preferred telephone number

Email address (please provide if you are willing to be contacted by email for the purposes of this application only)

National Insurance Number (if invited for interview, you may be asked to show original documents to prove your eligibility to work and reside in the UK)

Do you hold a full UK driving licence? Y/N

Do you have the use of a car? Y/N

1 EMPLOYMENT HISTORY

Current or most recent employer (if self- employed, please describe briefly).

Please give: Name of employer Address of employer Nature of employer’s business

Your job title in current or most recent employment or self employment

Current professional salary scale (if applicable. You may be asked to provide evidence of this). Please provide both the scale reference/description, and also the full- time equivalent annual gross salary amount that relates to it.

What period of notice would you be required to give to your current employer?

Dates started/finished working for current or most recent employer, and brief reasons for joining and leaving

Previous employment/self-employment history

Please provide the following details of your previous employment, ensuring that you explain any “gaps”. Continue on a separate page if you prefer:

Dates Name of Employer Your job role/title Brief reasons for joining and From - To leaving

2 EDUCATION HISTORY – you may be asked for proof of grades and qualifications Secondary education

Please give: Name of school Location (city or town) of school Dates attended

List of GCSE/O-levels or equivalent, with grades obtained

Further education

Please give: Name of school or college Location Dates attended

List of A-levels or equivalent, with grades obtained

Higher education

Please give: University or college attended Dates attended

Degrees or equivalent, with grades obtained (please describe clearly)

Other professional training or qualifications

Please describe any other significant training or qualifications you hold, giving dates obtained. Please describe clearly.

Remember that we are particularly interested in your formal training/qualifications in respect of children who are deaf, or who have other special needs.

Please ensure you provide details of your membership of professional bodies.

3 Please tell us why you would like to work for The Elizabeth Foundation and do this job. Tell us about the specific experience and skills you have, which make you well-suited for it. Also tell us a bit more about yourself as a person, you interests and hobbies. Tell us about anything else you think we should know to help us decide about your suitability for this role. Please continue on a separate sheet if you wish.

4 References

Please provide details of two confidential referees, one of which should be your present employer (if applicable). We will not contact referees without obtaining your permission first.

Please give Name, Contact Address, Contact Telephone Number, Contact email (if known/available) and describe how long the referee has known you and in what capacity.

Referee One: Referee Two:

EMPLOYMENT CHECKS Rehabilitation of Offenders Act 1974 (Exception) Order 1975 Normally under the above Act, some criminal convictions do not have to be disclosed after a period of time when they become “spent.” This does NOT apply to certain posts that are required to have CRB disclosure. Due to the nature of the work for which you are applying (working directly with vulnerable children), you MUST answer the following questions about current and ALL previous criminal convictions. Any information will be treated with the strictest confidence and will be considered only in relation to this application. Failure to disclose this information could lead to your application being rejected, or if you are appointed, to dismissal if it is subsequently learnt that you have a criminal conviction. Please delete as necessary:

Have you ever been cautioned or convicted of a criminal office? If Yes, please give details of the Yes/No cautions or convictions and dates. You may set this out on a separate sheet in clearly marked envelope addressed to Dr Sue Campbell (CEO), to accompany this application.

Have you ever been charged with any offence not yet brought to trial? If Yes, please give details of the Yes/No charge and the date of the hearing (if known).

Have you ever had a CRB check which resulted in disclosure of information? If Yes, please give Yes/No details.

Have you ever been disqualified from working with vulnerable children or vulnerable adults? If Yes, Yes/No please give details.

Have you ever been dismissed from a job working with children? If Yes, please give details. Yes/No

To submit this job application form, please either:

1 print and fill it in manually and clearly, OR complete it electronically and then print it, and then post it to:

Julie Hughes, The Elizabeth Foundation, Southwick Hill Road, Cosham, Hampshire, PO6 3LL

2 fill it in electronically and save it on your computer as “(Your name) application Specialist SaLT Elizabeth Foundation” and then email it to [email protected]

Remember to keep a copy for your own reference. Closing date for receipt of application forms is 29 November 2013

5 DECLARATION

I declare that to the best of my knowledge the answers given to the questions above are full and correct. I may be asked to provide evidence of training and qualifications. I understand that this job may be subject to identity checks and/or CRB/DBS/other checks to help ensure my suitability to work with vulnerable children. If appointed, I understand that if I have made a false statement or material omission then my contract of employment could be subsequently terminated.

Signature of Candidate ...... Date ......

Further information:

You may provide a CV if you wish, but you should still ensure that this Job Application Form is fully completed. We will do our best to ensure that all candidates receive a response from us, but please accept our apologies for any delay. General enquiries by telephone about your application will not be accepted. Thank you for your application.

About The Elizabeth Foundation – www.elizabeth-foundation.org

The Elizabeth Foundation believes that every child has the right to be given the opportunity to learn to listen and talk. We provide a range of services and support to young deaf children and babies and their families.

Registered office: The Elizabeth Foundation, Southwick Hill Road, Cosham, Hampshire, PO6 3LL. A company limited by guarantee and registered in England and Wales number 1960980. Registered charity number 293835.

The Elizabeth Foundation is committed to an equal opportunities policy.