Blissful Healthcare Registration Form

Blissful Healthcare Registration Form

Fill out the form carefully for registration
Position applied for:

Date of application How did you hear about the company?
Name *

First Name Last Name
Nationality:
Gender
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Mobile Number

Area Code Phone Number
Phone Number *

Area Code Phone Number
National Insurance Number *
Are you a LTD Company? *
If YES, please provide LTD Company details:
NMC PIN NO: (If applicable)
Which Language do you speak?
Have you ever been convicted of an offence? *
Do you have permission to work in the UK? *

Yes No
Are you a car driver? *

Yes No
Next of Kin: *
Relationship: *
Contact Address: *
Contact Tel No: *
Bank details
Bank name: *
Account name: *
Account No: *
Sort Code: *
Qualifications and Education

Employment History
University/ College: (including dates attended)
Employment History: (including dates attended) *
DBS
Are you willing to undergo a full enhanced DBS with this application for work? *

Yes No
Are you willing to pay the required fee of £49.60 for a DBS Disclosure check? *

Yes No
References

Please give the names of two employers we can contact for an employment reference including the most recent employer.
Name of Employer: *
Referee name: *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your job title: *
Referee Phone Number

Area Code Phone Number
Referee Email *
example@example.com
Reference

Reference number 2
Name of Employer: *
Referee name: *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your job title: *
Referee Phone Number

Area Code Phone Number
Referee Email *
example@example.com
I agree for you to contact these references and only once references have been received will my application go any further. I certify that the information on this form if the best of my knowledge correct. I understand that any engagement entered into will be subject to satisfactory references being received and a satisfactory DBS disclosure.
Signature: *

Clear
Date

Month Day Year
Date
Skills and Experience checklist
Please tick:

Community Care, Hospitals, Care Homes, Nursing Homes EMI/ Dementia Homes Adults with Learning Disability Adults with Mental Health issues Children with Mental Health Issues Physical Disability Children’s Homes Supported Tenancy Respite Centres Day Care Centres Prison Services Hospices Sheltered Accomodation Autism/ Aspergers Syndrome Acquired Brain Injury Palliative Care Parkinson’s Disease Diabetes Epilepsy Catheter Care Stoma Care Administration of Medicines Challenging Behaviour Person Centred Planning Record Keeping Bath/Shower/Strip wash Mouth Care Care Of Feet Dressing/ Undressing Bed Bath Emptying Catheter Bag Challenging Colostomy Bag Recording Fluid Intake Moving and Handling Service Users Use of Walking Aids Use of Hoists Current Moving and Handling Course Preparation of Meals Feeding Service Users Pressure Area Care Experience of Caring for Terminally Ill Answering Telephones Taking messages Bed making Changing a bed with a service user in it Light Housework Experience of Dementia
Skills and Experience checklist

*Nurses only*
Male Catheterisation Female Catheterisation IV Cannulation IV Medication IV Therapy Defibrillation Peg feeds Tracheotomy Care Patient controlled analqesia Phlebotomy O2 Therapy inc Nebulisers Wound care Stoma care Drains Endoscopy Use of suction equipment Bladder washouts B.M monitoring Sub- cutaneous fluids Naso- gastric tubes Theatres/ Recovery Neurology Intensive care units Coronary care Chest wards A & E Paediatrics Orthopaedics Haematology Oncology Cardiothoracic
Individual Training Record
Please tick ALL training that you have completed: (Please provide evidence of this)

Moving and handling practical Health and safety Fire safety Infection control First aid Deprivation of liberty safeguards Medication Epilepsy Mental capacity act Safeguarding of vulnerable adults Control and restraint
I can confirm that the information above is a true record of my training history *

Yes No
I am willing to attend mandatory training/specialist training as and when required *

Yes No
I can confirm I am happy to go through Blissful healthcares training before I can start to work with them . The charge is £30.00 Signature *

Clear
Health Declaration

Do you have or have you ever had any of the followings:
Do you have or have you had any of the following:

Any serious infectious diseases? Stomach, bowel problems, infections or food poisoning? Any allergy (including hay fever)? Fainting spells, blackouts or epilepsy? Any vision problems not corrected by glasses? Ear problems, infections or hearing defect? Dermatitis, eczema or any skin problems? Joint or back problems? Any disability? Depression/ mental illness / eating disorders? Diabetes? Are you taking any regular medication? Do you have any health problems that we should be aware of (including pregnancy) Chickenpox (Varicella) Hepatitis HIV/ AIDS
I declare that all the above is true to the best of my knowledge. I am willing to provide details of my GP should the company require a medical report. Signature: *

Clear
EQUALITY AND DIVERSITY MONITORING FORM

Blissful healthcare is committed to Equal Opportunities in employment and welcome applications from all sections of the community. In order to ensure the effectiveness of this policy and for no other purpose you are requested to place a tick in the appropriate boxes below and complete the details as required. The information is exclusively for monitoring purposes and will be kept strictly confidential.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job applied for:
Date of birth:

Day Month Year
Date
Sex:

Male Female Prefer not to say
Status:

Single Married Divorced Widowed
Please select the appropriate box that indicates your cultural background:
Any other background, please specify:
Please select the appropriate box that indicates your religious background:
Any other religion, please specify:
Sexual Orientation

Heterosexual Gay/ Lesbian Bisexual Prefer not to say
The Disability Discrimination Act 1995 defines a disabled person as anyone who has a physical or mental impairment which has a substantial and long term effect on their ability to carry out normal day to day activities.
Taking this definition into consideration do you have a Disability?

Yes No
If YES, then please give details:
Date:

Month Day Year
Date
Signature *

Clear
FAILURE TO COMPLETE THIS FORM WILL NOT AFFECT YOUR APPLICATION. If you believe that there has been unfair discrimination in making the appointment, there is a process of investigation available, subject to reasonable grounds for suspicion being identified. If you wish to pursue an unfair discrimination complaint, please contact the Director of Blissful Healthcare.
Working Time Directives
I understand that I am under no obligation to work more than an average of 48 hours in any week - these hours include any hours that I work with other employers as well as Blissful Healthcare.

I furher understand that I may work more than 48 hours per week if I wish.

under the terms of engagement, I realise that I may turn down any assaignment at any time, for any reason without detriment.

By signing this declaration, I am signifying that any access of an average of 48 per week are worked by my choice, but also make it clear that this declaration does not mean that I will work more than an average of 48 hours in any week.

I undertake to inform if the total number of hours I work in a week from all forms of employment exceeds 48, in order that Blissful Healthcare may take this into consideration before offering work to me.

I understand that it is necessary to inform the agency of my availability for work each week and accept that there is no guaranteed hours of work.
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
Identification Authority
In line with the requirements of current legislation I give Blissful Healthcare my permission to hold and transmit my photograph and date of birth, when necessary, to those clients who require identification cards when on assaignment for them.
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
Confidentiality Agreement
I confirm that during every assaignment and afterwards:

1) To hold information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I acknowledge that no information is to be removed from the clients premises without the permission of the client.

2) To use such information only for the purpose of the week for which it was given.

3) Not to disclose to any third party or copy the information except as it required in the course of my duties.

4) Any breach, either by me or a third party, may result in legal proceedings being brought by the Client against me to recover any losses that have occurred as a result of a breach.
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
Any conversations that compromise the patient relating to the above statement may jeopardise my position with Blissful Healthcare.
Audit

I am aware that during the course of my time with Blissful Healthcare, my information may be required by an external party for auditing purpose. This includes my personal data and any other data relating to the work in question given to me by Blissful Healthcare.I hereby give my consent for Blissful Healthcare to share my information and documents for the purposes of an audit for an auditor to check and review should the occasion arise.
Name

First Name Last Name
Date

Month Day Year
Date
Uniform Deduction Form
I accept that I must wear a uniform together with black trousers and black shoes ( no high heels or trainers) on any care assaignment with Blissful Healthcare. Jeans and non - closed shoes are not acceptable.
My Uniform size is:
I am happy to pay a total fee of £20

i understand that I must not wear my uniform when working for anyone other than Blissful Healthcare.

I also give permission to Blissful Healthcare, to make deductions from my wages for the cost of my uniform.

I understand and agree to the above:
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
Working with Challenging Behaviour
When working in this industry there are hazards associated with the industry. I appreciate and accept that one of these hazards is possible aggressive behaviour from challenging service users. Service users may present challenging and aggressive behaviour and this is out of the control of Blissful Healthcare.

I understand and accept that I am under no obligation as an agency worker to accept assaignments. I accept that there is this risk and accept that this risk is as a result of the industry and not of Blissful Healthcare.

I understand that if I am unhappy with an assaignment I can withdraw my submission at any time with reasonable notice dictated in my contract for service, and as a result will not hold Blissful Healthcare liable for any injury or loss of earnings as an agency worker.

I understand that as an agency worker I am not employed by Blissful Healthcare and therefore I am not guaranteed any assaignments and have no claim against Blissful Healthcare at any time for any reason whatsoever for loss of any earnings as an agency worker.

I understand that if I am injured or affected in any other way whilst on an assaignment that this is not the fault or liability of Blissful Healthcare.

I understand and agree to the above in its entirely:
Name

First Name Last Name
Date

Month Day Year
Date
Signature: *

Clear
Charges
i also understand that I need to give at least 12 working hours notice if cancelling a shift or I will be charged a fee of up to £50, we understand there are certain situations that cannot be helped and we will always take these into consideration. When cancelling a shift I understand that I should call the office phone numbers as well as texting.

I understand and agree to the above:
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
SEVERABILITY

If any of the provisions of these Terms shall be determined by any competent authority to be unenforceable to any extent, such provision shall, to that extent, be severed from the remaining Terms, which shall continue to be valid to the fullest extent permitted by applicable laws.
NOTICES

All notices which are required to be given in accordance with these Terms shall be in writing and may be delivered personally or by first class prepaid post to the registered office of the party upon whom the notice is to be served or any other address that the party has notified the other party in writing, by email or facsimile transmission, when that email or facsimile is sent.
GOVERNING LAW AND JURISDICTION

These Terms are governed by the law of England & Wales / Scotland and are subject to the exclusive jurisdiction of the Courts of England & Wales.
Name

First Name Last Name
Date

Month Day Year
Date
Signature *

Clear
GDPR Consent

In order to continue to keep you up to date with your payslips and future job opportunities, please respond below verifying you are happy to continue to receive this communication from us. As of the 25th May 2018, we can no longer continue to communicate with you via Email, SMS or Post, unless we receive your permission to do so due to the new GDPR regulations.
Failure to respond will result in us being unable to send you your payslip via email on a weekly basis as well as any communication relating to Blissful Healthcare’s activity.

I would like to receive communications via: *

	Yes	No
Email
Post
Landline
Mobile

Name

First Name Last Name
Signature *

Clear
Please select the branch you would like your Application Form submitted to: *
Should be Empty:

Blissful Healthcare Registration Form

Bank details

Qualifications and Education

DBS

References

Reference

Skills and Experience checklist

Skills and Experience checklist

Individual Training Record

Health Declaration

EQUALITY AND DIVERSITY MONITORING FORM

Working Time Directives

Identification Authority

Confidentiality Agreement

Audit

Uniform Deduction Form

Working with Challenging Behaviour

Charges

SEVERABILITY

NOTICES

GOVERNING LAW AND JURISDICTION

GDPR Consent