Templesprings Childcare Job Application Form

References & DBS Checks

Please give names, and contact details of two referees, one of whom should be your present/most recent employer. We may approach this referees prior to interview/job offer.
1. Professional Reference Details
Professional Reference Full name *

First Name Last Name
Telephone Number *
Relationship *
E.g Manager, HR
Email *
example@example.com
Can we approach this referee prior to interview/job offer? *

Yes No
2. Personal Reference Details
Personal Reference Full name *

First Name Last Name
Relationship *
e.g Parent, Friend
Telephone Number *
Email *
example@example.com
Can we approach this referee prior to interview/job offer? *

Yes No

Your Role
Why do you want to work with Templesprings Childcare Services Ltd.? *
What experience do you have for the role? *
What experience do you have in working with children and young people? *
What skills do you feel you can bring to your role? *

Psychological Wellbeing and General Health

Important Note: The questions on the next page are about your health, both physical and psychological. Please answer the questions honestly. There are no correct answers and no set issues that immediately disqualify you from participating. As we work with children and as part of our safeguarding policy, the information we request is important to maintain a safe environment. If there are any issues that are of concern to us, we shall discuss them with you. The information is held in confidence and will only be accessible to those people who need to know.
Psychological Well-Being
1. Have you ever been treated for depression? *
If yes, when was this and what treatment did you receive?
2. Have you ever attempted suicide? *
If yes, when was this and how did you attempt suicide?
3. Have you ever experienced violence? *
If yes, when and from whom?
4. Have you ever been violent? *
If yes, when and towards whom?
5. Have you ever suffered with any other mental health/ psychological problem? *
If yes, what was this , when was this and what treatment did you receive?
6. Have you ever been to see a psychologist, counselor, therapist or psychiatrist? *
If yes, when was this, how long were you receiving treatment and why?
7. Have you ever been admitted onto a psychiatric ward? *
If yes, when was this; how long were you an in-patient? Why were you admitted and which unit were you admitted to?
8. Are you currently in any form of therapy, counselling, psychological or psychiatric treatment? *
If yes, 1) why are you receiving treatment; 2) since when have you been receiving treatment; 3) who is treating you and 4) what is their contact details?
General Health
9. Do you smoke? *
If yes, how many per day?
10. Describe your alcohol consumption? *

Never Occasional (several times a month) Sometimes (2-3 times weekly) Often (more than 3 times a week)
11. Do you use any drugs other than prescribed medications? *
If yes, what drugs and how often
12. How often do you exercise? *

Never Occasional (several times a month) Sometimes (2-3 times weekly) Often (more than 3 times a week)

Please upload a copy of your latest CV* *

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Have you been cautioned, subject to a court order, bound over, received a reprimand or warning or found guilty of committing any offence since the date of your most recent enhanced DBS disclosure?
Have you been cautioned, subject to a court order, bound over, received a reprimand or warning or found guilty of committing any offence either before or during your employment at this setting?
Have you ever been known to any Children’s Services department or police as being a risk or potential risk to children?
Are you ‘Disqualified for Caring for Children’?
Have you committed any offences against a child?
Have you committed any offences against an adult (e.g. rape, murder, indecent assault, actual bodily harm etc.)?
Have you been barred from working with children (DBS)?
Have your own children been taken into care?
Have/are your own children the subject of a child protection order?
Has your name been placed on the DBS barring list
Do you have any special requirements to enable you to attend an interview?
Have you lived or worked abroad?
Have you been the subject of any investigation and/or sanction by any organisation or body due to concerns about your behaviour towards children?
Have you ever been the subject of disciplinary sanctions or been asked to leave employment or voluntary activity due to inappropriate behaviour towards children?
Do you have any unspent convictions in the UK or overseas?

Application Form

Personal Information

Employment / Educational Status

Ethnic Origin

References & DBS Checks

1. Professional Reference Details

2. Personal Reference Details

Self Disclosure Form

Your Role

Psychological Wellbeing and General Health

Signatures