Grace Care Live-In Care Application Form SECTION 1 – DOCUMENT REQUIREMENTS Please ensure the following documents are included with this form: • Certified Copy of Identity Document • CV • Proof of Address SECTION 2 – PERSONAL DETAILS Title Initials First Name Surname Date of birth Y Y Y Y M M D D Gender M F Driver's License Yes No ID/Passport Number Country of issue Marital status Nationality Telephone number Mobile number Email address Physical address Next of Kin Next of Kin Telephone No. SECTION 3 – EDUCATION Highest Grade Passed Year School Post-Secondary Qualification Initials Institution Other Qualification First Name SECTION 4 – MOST RECENT WORK EXPERIENCE Surname Job Title Company Reference Length of Employment (In Years) Reference Contact Number SECTION 5 – KNOWLEDGE SKILLS AND EXPERIENCE Grace Care is a Subsidiary of the Dr Grace Sangoni Foundation Santa Complex, 1 Nqadu Road, Ncambedlana, Mthatha T: 061 521 3465 e: info@dgsmc.org.za w: www.drgracesagoni.org Page 1 of 2 I have the following care skills, care qualification and care experience. Please select all the relevant boxes that apply (Proof maybe required) Care Skills Care Qualifications Asperger's Medical Behaviours that Challenge Nursing Cancer Care NVQ Health and Social Care Catheter Care Occupational Therapy Dementia (Alzheimer) Dr Grace Sangoni Memorial Certificate End of life / Palliative Care No Care Qualifications Epilepsy / Buccal midazolam Incontinence General Care Experience Learning Disability (Autism, Down Syndrome etc) Care for close relative or loved one Manual Handling Home Care Medication Training Live in care work Mental Health (Schizophrenia, Depression, Bi-Polar) Other Care Work Multiple Sclerosis Older People English Language Level Parkinson’s Very Basic Physical Disabilities Conversational Sensory Disabilities (Blind / Deaf) Fluent Spinal Injury Stoma Preferred Location Stroke / Brain Injury Durban Tracheostomy East London Peg Feeding Johannesburg SECTION 6 – DECLARATION AND CONSENT I confirm that the information disclosed in this application form is relevant and correct and can be verified by references from previous employers and/or any professional bodies specifi I hereby give my FULL CONSENT for information I have disclosed to be divulged to companies or agents as deemed necessary by Grace Care in relation to my application for work including references. I declare that I have no unspent convictions and there are no prosecutions pending at this time. I also undertake to inform Grace Care of any prosecution that occurs whilst my details are held by Grace Care. Whilst on assignment from Grace Care I will regard all available information as confidential and I will not divulge it to any third parties plus I will comply to the Health & Safety regulations of all the service users I am assigned to. I confirm that I have applied / re-applied to Grace Care of my own free will and have not been offered any inducement to do so. Name Date Signature Grace Care is a Subsidiary of the Dr Grace Sangoni Foundation Santa Complex, 1 Nqadu Road, Ncambedlana, Mthatha T: 061 521 3465 e: info@dgsmc.org.za w: www.drgracesagoni.org Page 2 of 2
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