LifeTouch Care

Staff Application Form

Personal

DBS

References

Clinical

Employment

Qualifications

Skills

Occ. Health

Equality

Declaration

Personal Details

Position Applied For *

Location Applying For *

Please specify the position *

Title *

First Name *

Last Name *

Date of Birth * Required for right-to-work checks and DBS compliance.

National Insurance Number * Required for payroll and tax purposes.

Address

Address Line 1 *

Address Line 2

Town / City *

Postcode *

Contact Details

Mobile Number *

Home Telephone

Email Address *

Travel & Mobility

Full UK Driving Licence? *

Yes No

Access to a Car? *

Yes No

Willing to Travel Between Visits? *

Yes No

Immigration Status

Immigration Status *

Right to Work in the UK? *

Yes No

Proof of right to work will be required.

Type of Visa Held

Right to Work Share Code Required for applicable visa holders.

Professional Misconduct

Have there been any proceedings of medical negligence or professional misconduct against you, or have you ever been suspended? *

Yes No

Please provide full details *

Next of Kin Details

Name *

Telephone *

Relationship *

Same as Above

Contact Address *

Step 1 of 10

DBS & Rehabilitation of Offenders

Criminal Records

This role requires an enhanced DBS check. The Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 applies to this position. You are required to disclose any convictions, cautions, reprimands or bind-overs, including those that would otherwise be considered "spent".

Do you have any criminal convictions, cautions, reprimands, bind-overs or warnings? *

Yes No

Please provide details *

Do you currently have criminal charges pending or are you under criminal investigation? *

Yes No

Please provide details

Have you ever been disqualified from working with children or vulnerable adults, or had sanctions imposed by a regulatory body? *

Yes No

Please provide details

DBS Check

This role requires an Enhanced DBS check. Do you consent to this? *

Yes No

I give my consent for Lifetouch Care to obtain a new DBS check or carry out a DBS Update Service status check as required.

DBS Update Service

Are you registered with the DBS Update Service? *

Yes No

DBS Update Service Certificate Number

Step 2 of 10

References

Please provide two professional referees who we may contact for a reference. One must be your most recent line manager or supervisor; the second should also be a previous manager/supervisor. Please ask your referees for permission before submitting. Personal email accounts (Gmail, Hotmail, Yahoo, etc.) will not be accepted.

Do you consent to us contacting your references prior to the interview? *

Yes No

I give my consent for Lifetouch Care to contact my previous employers for references in support of my application. *

Reference 1 — Most Recent Employer

Full Name *

Job Title *

Organisation / Employer *

Relationship to You *

Professional Work Email * Must be a professional / work email address.

Contact Number *

Reference 2 — Previous Employer

Full Name *

Job Title *

Organisation / Employer *

Relationship to You *

Professional Work Email * Must be a professional / work email address.

Contact Number *

Step 3 of 10

Clinical & Professional Details

Professional Registration

Are you a Registered Nurse?

Yes No

NMC Pin Number

NMC Renewal Date

Additional Professional Registration

Do you have any other professional registration?

Yes No

Registration Name

Registration Number

Revalidation (Nurses Only)

Next Revalidation Date

Professional Indemnity Insurance (Nurses Only)

Defence Body

Policy Number

Expiry Date

Step 4 of 10

Employment History

Please list your employment history in reverse chronological order, starting with your most recent employer. Include all employment and explain any gaps.

Employment 1 — Current / Most Recent

Employer Name *

Job Title *

From *

Reason for Leaving

Employment Gaps

Do you have any gaps in your employment history? *

Yes No

Gap 1

Gap Start Date

Gap End Date

Reason for Gap

Step 5 of 10

Qualifications & Training

Relevant Qualifications

Qualification 1

Qualification

Institution

Date Achieved

Care-Related Training

Training 1

Training Course

Date Completed

Step 6 of 10

Skills & Experience

Please describe your experience in domiciliary care or a similar role *

What skills do you possess that make you suitable for this role? *

Step 7 of 10

Occupational Health Questionnaire

This information is required to ensure your fitness for work in a healthcare setting. All information is treated in strict confidence and will only be used by Occupational Health professionals.

Health Screening Questions

Please answer all questions. Where you answer Yes, please provide details in the box provided.

Step 8 of 10

Equality & Diversity Monitoring

At Lifetouch Care Ltd, we are committed to promoting equality, diversity, and inclusion in all aspects of our work. This form helps us monitor our recruitment practices and demonstrate compliance with the Equality Act 2010 and local authority requirements. Completing this form is voluntary, and the information you provide will be kept strictly confidential. It will be used only for monitoring purposes and will not affect your job application.

The Equality Act 2010 defines a disability as a physical or mental impairment that has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities. Any information provided regarding disability or health conditions is collected solely for equality monitoring purposes, will remain confidential, and will not influence your application. By completing this form, you help us uphold our commitment to equality, diversity, inclusion, and social value delivery.

Age Group *

Gender *

Male Female Non-binary Prefer not to say

Do you consider yourself to have a disability? *

Yes No Prefer not to say

Lifetouch Care is a Disability Confident employer and will make reasonable adjustments.

Ethnicity *

Religion or Belief *

Sexual Orientation *

Step 9 of 10

Declaration & Submission

Additional Information

Is there anything else you would like to tell us about your application?

Working Time Regulations

Under the Working Time Regulations 1998, workers have the right to work no more than an average of 48 hours per week. You may choose to opt in or opt out of this regulation.

Working Time Regulations Preference *

Opt In (comply with 48-hour limit) Opt Out (agree to work more than 48 hours if required)

Declaration

I consent to Lifetouch Care processing my personal data in line with UK GDPR and the Data Protection Act 2018 for recruitment and employment purposes. I authorize verification of my identity, right to work, professional registration, qualifications, employment history, and references, and I consent to Enhanced DBS checks via the Update Service, including periodic status checks. I agree to occupational health assessments, vaccination status checks, and the processing of my bank details and National Insurance number for payroll.

I consent to my data being shared with auditors, regulatory bodies, and prospective employers for compliance purposes, and I agree to maintain confidentiality regarding all sensitive information related to Lifetouch Care, its clients, and third parties. I also consent to receiving marketing communications about vacancies and referral initiatives.

I opt in to working beyond 48 hours per week under the Working Time Regulations 1998, with the right to withdraw this consent with three months' notice. I acknowledge my data subject rights and confirm that my referees have been informed of potential contact.

I consent to Lifetouch Care capturing and securely storing a screenshot or image during my interview for identity verification and safer recruitment evidence. I consent to contact with previous employers, including those not listed as referees, where required for safeguarding or regulatory compliance. I agree to the storage and sharing of my training and competency records and the use of my photograph for ID and security purposes. I consent to the use of electronic signatures, digital monitoring of my training compliance, and the secure storage of my emergency contact details. I also consent to Occupational Health contacting my GP or specialist if needed to confirm my fitness for work.

I have read, understood and agree to the above declaration. *

Signature

Please sign below or upload a signature image *

Draw Signature Upload Signature Image

Accepted formats: JPG or PNG. Maximum file size: 3 MB.

Date of Declaration

Date *

Step 10 of 10

✓

Application Submitted

Thank you for submitting your application to Lifetouch Care.

Our recruitment team will review your application and be in touch shortly.

Email: jacob@lifetouchcare.co.uk | Tel: 01902 544 824

LifeTouch Care

Personal Details

DBS & Rehabilitation of Offenders

References

Clinical & Professional Details

Employment History

Qualifications & Training

Skills & Experience

Occupational Health Questionnaire

Equality & Diversity Monitoring

Declaration & Submission

Application Submitted

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