Application form FOR LINK'D IN

Application Form
Thank you for registering an interest in applying for a position within our company. Appletree Support is a company that provides care and
support for children and young people with disabilities and health care needs.
Appletree Support is an equal opportunities employer and therefore seeks to recruit individuals on the basis of their suitability for a post
within caring for children and young people.
Should you have any questions or queries regarding the information in this application pack, or you require further information, please do not
hesitate to contact us on 023 9245 5888.
The application process
1. Fully complete the application form, making sure that the criminal declaration form and the application form as a whole are signed.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Regulation 17 Good governance
Regulation 19 Fit and proper persons employed
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2. Please read and sign the enclosed Job description and personal specification and return them together with your completed
application form.
3. All positions are subject to two satisfactory references. These references must be from two previous employers.
4. If your application is successful you will be contacted by phone or Letter to ask you to come for an interview.
5. Once your application has been processed, and should it be successful, we will contact you by post to formally offer you a position
within our company.
6. Once you have accepted the position you will be asked to attend an induction course, prior to commencement of employment. At
this induction Appletree Support will ensure that you are issued with an Employment handbook code of conduct and an ID card.
This Application form is also available in large print, and on tape on request.
Title:-
Miss
Forenames(s):
Lisa Marie
Surname:
Haines
National Insurance number:
Please ask
Date of birth:
27.05.1994
Any pervious Surname:
No.
2

Address:
Please ask
Home Telephone number:
Unavailable.
Mobile Telephone number:
Please ask.
Email Address:
lisa.haines5@hotmail.co.uk
Position applied for: Support Worker
Date employment can start: As soon as possible.
Are you a UK resident?
Yes
Do you hold a work permit?
Not needed.
Do you hold a valid driving licence?
Yes
Do you have access to a vehicle?
Yes
Do you have business insurance?
No
If yes who is your insurance with:
Admiral Car Insurance
Where did you see this post advertised? My friend recommended your company.
Are you registered or a member with a professional body? No
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If yes who are you registered with or a member of? X
Data protection act 1998
Information on these forms may be held on computerised records. Strict confidentiality will be observed and disclosures will only be made to payroll and administration purposes.
Entitlement to work in the UK
To comply with Asylum and Immigration Act 1996 (as amended by S. 147 by the Nationality and Immigration and Asylum act 2002) all prospective employees will be required to supply evidence of eligibility to work
in the UK. If you are selected for interview you will be provided with further information detailing what documents will be required.
Training and previous experience details. Please tick the relevant boxes if you have experience in this field.
Experience For which length of time
Disability Yes 140 hours (Oct 2014 – March 2015)
Learning Disabilities No
Physical Disabilities Yes 140 hours (Oct 2014 – March 2015)
Palliative care No
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Autistic Spectrum No
Challenging behaviour Yes 2 full days of shadowing experience
Complex medical needs Yes 140 hours (Oct 2014 – March 2015)
Sensory impairment Yes 140 hours (Oct 2014 – March 2015)
Hours will be flexible and can change from week to week due to client demands. Please give an
indication of the amount of hours you are available to be offered work.
10 – 15 hours
Any additional information:
I would like to take on as many hours as possible and I can be flexible
during certain evenings and over various weekends too.15 – 20 hours
20 – 25 hours
25 – 30 hours X
5

Education & Employment History
Please indicate your full employment and education history. If you have not been in employment over any period of time, could you please
state the dates and the reason? (E.g. Unemployed, Left to have child, etc.)
Educational History
Name of collage/ university Qualification Date From Date to Level / Grade
University of Portsmouth BSc (Hons) Psychology September 2012 June 2015 Finish with a upper bound 2:1.
Southdowns College
A-Levels
A-Levels September 2010 June 2012 Psychology (A)
Health and Social Care (B)
Sports Studies (B)
The Hayling College GCSES September
2005
July 2010 11 GCSES graded A-C, including Maths,
English and Science/additional science.
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EMPLOYMENT HISTORY
PRESENT EMPLOYMENT: *Present employment is now Apple Tree, please ask me for more details regarding my salary, job
description etc.*
Employers Name & Type Job Title Dates Salary Notice Required
From To
JAN HAINES (MOTHER)
GEOFF FOOT ESTATE
AGENTS
7 ELM GROVE,
MENGHAM,
HAYLING ISLAND,
HAMPSHIRE,
PO11 9EA.
Part-time
Trainee Sales
Negotiator
31.05.14
Present
£1,200 Per
annum
2 weeks or less.
Reason for wishing to leave present employment:
To obtain a mental health/psychology related occupation.
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EMPLOYMENT HISTORY CONTINUED
(Enter your most recent employment first. Please include Voluntary & unpaid work. Also account for any breaks in
employment).
Employers Name & Type Job Title Date (month &
year)
Reason for leaving
From To
Currently completing voluntary
work experience at the Portsmouth
University Dog Cognition Centre:
Dr Juliane Kaminski
Institute of Marine Sciences,
Ferry Road,
Eastney,
Portsmouth,
PO4 9LY.
As part of my degree, I completed
140+ hours of voluntary work by
shadowing a clinical psychologist:
DR GREGORY CLARKE
Volunteer
Research Assistant
22.05.15
07.10.14
Present
10.03.15
Still currently working in a voluntary position.
140 - 175 hours completed
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ST JAMES MENTAL HEALTH
HOPSITAL
LOCKSWAY ROAD,
SOUTHSEA,
PORTSMOUTH,
HAMPSHIRE,
PO4 8LD.
MR MIKE BERRY
THE OLIVE LEAF PUBLIC
HOUSE,
48 SEA FRONT,
HAYLING ISLAND,
HAMPSHIRE,
PO11 9HL.
Public House Staff
03.08.09 30.05.14
Was looking for a different type of work
experience.
9

SARAH GASHER
TESCO EXPRESS (WEST
TOWN),
28 STATION ROAD,
HAYLING ISLAND,
HAMPSHIRE,
PO11 0EG.
Customer Sales assistant
09.07.12 07.10.12
Temporary summer position for additional wage
and experience. However, was offered a
permanent position.
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Supporting Statement
Hayling Island – school pupil peer mentor
Since my early adolescent years, I had always been interested in helping and supporting people and
putting other people’s needs before my own. I found it easy to communicate and gain the trust of friends,
colleagues and others around me, even from such an early age. At school, I was appointed the role of a Peer
Mentor. This was a position given to students deemed mature and responsible enough to take on the
troubles of a fellow pupil, as well as, keeping on track with GCSE revision. Their problems ranged from
being bullied or abused at home, to not coping with the stress of exams. From this, I began to develop an
interest in counselling and found psychology to be an appropriate pathway. Thus, during May this year
(2015), I will be completing my final exam from the University of Portsmouth’s BSc (Hons) course in
Psychology. Hoping to finish with a predicted 1st
class or high 2:1, will ensure that I am a step closer to
achieving my future career goal of becoming an accredited counselling psychologist, where I can continue
to help people who are struggling with life’s pressures.
Hayling Island – class room assistant placement
Whilst at school, I was given the opportunity to undergo a two week voluntary placement of full-time
work at a location of my choice. For this, I chose to work with children at Mill Rythe Infant School as a
class room assistant. This involved teaching a ‘year 2’ age group various core subjects such as English,
maths and science. Physical education was also important and I was given the opportunity to teach them
some various stretches and posture helping exercises. In addition, there was also a lot of encouragement for
the children to be creative and therefore given some arts and crafts activities to complete. I believe this
experience was good for me as it can it taught me to recognise children’s development needs (e.g. creativity
and imaginative play can help brain development, or how a healthy diet and exercising regularly can help
muscular and bone development). Encouraging child development is very vital and from this experience I
also recognised how it needed to be done correctly, as it could have a huge impact on the children’s present
and/or futures. Therefore, I also learnt to understand the pressures and responsibilities that come with
helping children and fulfilling their individual needs (with love, care and security being the most
important).
Portsmouth - clinical placement experience:
As part of my degree’s work placement module, I pursued the job of a research assistant at St James’
mental health hospital in Portsmouth where I would be working with people suffering from mental and
physical disabilities. It was here with the chronic pain team, that I gained the invaluable experience of
observing group treatment sessions such as mindfulness mediation and tai chi. This allowed me to create a
positive rapport with various groups, which was soon noticed by my senior manager Dr (GC). He then
allowed for my job role to evolve and gave me further responsibility of telephoning patients to ask for
sensitive and personal information (including depression and anxiety referral questionnaire answers, used in
tests such as the PHQ-9 and HAD-7). Thus, allowing further development of my confident verbal
communication skills and professional telephone manner.
Additionally, my key role was to create my own data-base for both South-East Hampshire and
Portsmouth patients, in order to observe the differences between pre and post scores from using the service,
as well as pre and post scores for individual treatments. To be successful when auditing this amount of
confidential data, I had to remain highly organised and have good time management skills. This was
especially vital as the data had to be presented by my manager and put before commissioners, in order to
keep the full bid that they were awarded. To complete this task, I used MS excel and therefore was able to
develop my IT skills further along with good problem solving skills, as manual data input can lead to
potential analytical errors. Thus, also ensuring that I remained detail conscious and kept records accurate.
Furthermore, liaising with a variety of professionals, from clinical psychologists to physiotherapists, has
helped me to perform effectively within a team as we worked together to provide the best service
experience for users of the service.
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Isle of Wight - sexual offender prison experience:
During my Easter break, I was able to gain contact with a mental health support worker who counselled
various sexual offending prisoners on the Isle of Wight. This gave me the experience of being able to liaise
with a variety of professionals, from clinical psychologists to social workers and various prison staff. From
this, I learnt the importance of networking and forming a good relationship with fellow members of staff. I
was also able to enhance my ability of keeping an open-mind when listening to personal accounts, which
could be especially difficult in some cases. As you can see from this, I am eager to learn and develop the
way I think about others. I always want to see others in the best possible light and think I would enjoy
working with the age group of your cliental and find it interesting to listen to their unique experiences.
Academic profile:
I purposely chose a mental health topic for my dissertation, as I knew this was the field of work that I
wanted to go into after university. I also chose it because I have a strong passion for encouraging people to
seek-help and talk to someone so they do not feel alone. Therefore, I feel like this job opportunity would be
more than appropriate for helping me fulfil my drive to encourage and help others to feel good about
themselves.
The aim of my dissertation was to measure the general public’s attitudes towards mental health
problems. Firstly, it focused on people’s own age; to see if that would affect their attitude towards mental
health. Secondly, I looked at the association between criminal behaviour and mental health problems to see
this affected people’s attitudes. By conducting this research, I found that people aged between 18-29 years
old would be more critical of their own (real or imagined) mental health problems, thus making them feel
embarrassed and not want to seek-help nor attempt to use services. When completing this task, I believe
that it allowed me to practice my already developed problem solving and time management skills,
especially when having to analyse data for 195 people and run in-depth statistical tests.
Furthermore, in relation to my academic background, during my second year of university we were
given the topic of child development to study. For this module, we studied various cultural differences in
the upbringing of young children and adolescents. I believe this taught me to uphold a great deal of respect
for others, no matter what their differences may entail (race, gender, religious beliefs, culture and status),
thus also helping me to practice the maintenance of an open-mind.
Outside interests:
Owning two horses is a great responsibility and has given me many opportunities to raise money for
various NHS charities such as the ‘Rocky Appeal’ and ‘Hampshire Air Ambulance’ through sponsorship. In
total, mum and I have raised over £300.00 by completing sponsored riding events across long distances. I
have also recently entered the great south run this year which is will be raising money for the ‘Revitalise’
charity and the Hayling Billy 5 run, which will be raising money for a Portsmouth charity called ‘Cystic
Fibrosis Kids’.
In relation to my current running of events, most Monday evenings I attend the Hayling College to help
coach two groups from the Hayling Island Netball Club, including the seniors aged 11+ and the adults aged
17+. Here we not only delivery skills and fitness practice, but we also teach the players about the
importance of maintaining a healthy diet and how to stay safe through appropriate stretching and cool down
sessions. Being part of this team and my other team in the Portsmouth league has allowed me to use my
own initiative, especially when planning group sessions as a coach. Simultaneously, playing has also
allowed me support and encourage other team mates, so that we can improve ourselves and succeed
together.
Finally, I hope you’ve enjoyed reading about my experience and would welcome the opportunity to meet
with you at interview in order to discuss my application in more depth. Thank you for taking the time to
read my supporting statement and I look forwards to hearing from you.
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References
Please give details of two referees who are able to comment on your honesty and integrity etc. Referees
must be your present and last employer.
I have a big list of references that have offered to support my application, please ask for more details.
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Rehabilitation of Offenders Act
Under the Act, an individual who has had a conviction or (convictions) for an offence, with certain
expectation, can be rehabilitated and allowed to treat the conviction as if it had never occurred. A
conviction will become ‘spent’ where the individual has not, after a period of time committed another
serious offence.
An employer may not under the act, ask a prospective employee if he/she has spent convictions during the
recruitment process. The Act makes it unlawful for an employer to discriminate in any way against the
employee or to dismiss him/her because of a spent conviction.
Exemptions
A conviction cannot be ‘spent’ under the act if it incurred a sentence of more than two and a half years in
prison or was a life sentence, preventative detention or the equivalent for young offenders.
In addition the act does not apply when an individual applies for a post which is concerned with the
provision of services which involve access to children or young people, older people, people with physical
and / or learning disabilities and people with mental health problems.
Therefore because of the nature of the work involved, the aforementioned employment is exempt from
the provisions of section 4 (2) of the
Rehabilitation of Offenders Act 1974 by virtue of the rehabilitation of offenders Act 1974 (Exemption)
Order 1975.
Applicants are therefore not entitled to withhold information regarding offences which for other purposes
are ‘spent’ under the provisions of the
Act.
Have you any criminal convictions?
If so please give details below
No Signature:
Have you any pending convictions?
If so please give details below
No Signature:
Signature: Date:
Failure to disclose any convictions, spent or unspent may result in disciplinary Action.
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Medical Declaration
This information is used for the purpose of assessing the medical fitness of candidates to carry out the
tasks involved with employment. This information is confidential and will only be disclosed to the
Recruitment Officer and the Service Manager.
Family Doctor
Name
Address
Telephone
Do you or have you suffered from any of the
following
Please give details
Back pain / slipped disc No I have none of the medical issues stated below.
Rheumatism No
Heart condition No
Dizzy spells No
Respiratory problems No
Skin disorders No
Any allergies No
Tuberculosis (BCG) No
Hepatitis No
Heart attack No
Mental ill health No
I declare that the above information is a true and accurate account of my medical history.
Signed: Date:
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Health Declaration
All Applicants are required to complete this health declaration. Any positive answers will not necessarily affect your
application.
1. Is your general state of health good?
2. Are you a registered disabled person? If yes please give details and specify and special needs which may relate
to your disability.
3. How much time have you lost from work due to illness in the last five years?
4. Please give details of any disease, disorder, hospitalisation or allergies you have experienced in the last three
years?:
5. Please give details of medication, drugs or treatment you are currently and/ or regularly receiving?:
6. Please list the vaccinations or immunisations you have had:
I declare that the statements are true and complete to the best of my knowledge and belief. I understand that my General Practitioner
may be consulted with my prior consent.
Signed: Date:
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Application Declaration.
The information contained in this application form is true, correct and complete.
I understand that any misrepresentation may invalidate my application/employment arrangements.
I certify that the information contained on this application form is accurate and true. I give my consent to
the processing, transfer and disclosure by the Company of all information submitted by me during the
recruitment process and throughout any subsequent periods of employment for pre-employment checks,
equal opportunities monitoring, payroll operations and training (Data protection Act 1988).
Print Name: Signature:
Date:
17

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