Carer Application

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Personal

Gender

First Name *

Last Name *

Date of Birth *

Registered Name *

Mobile *

Email *

Address 1 *

Address 2

Town *

Postcode *

Location *

T Shirt Size *

Emergency Contacts

Doctor's Name *

Doctor's Contact *

Emergency Contact Name *

Emergency Contact Number *

Pre Existing Conditions

Pre-existing medical conditions?

Medical Condition Details

Risk of contracting any disease

Risk of contracting any disease?

Risk of contracting any disease Details

Contagious or communicable illness?

Contagious or communicable illness?

Contagious or communicable illness Details

Allergic to medications?

Allergic to medications?

Details of Medication Allergies

Friends

Applying With Friends?

Friends Who

Experience with Special Needs

Experience with Special Needs

Details of Experience with Special Needs

Other Medical

Last Tetanus Date

First Aid Certificate

First Aid EXP Certificate Date

Peg

Do you have a Certificate to Use a Peg

Peg Cetificate

Epipen

Do you have a Certificate to Use a Epipen

Epipen Cetificate

Nappy

Are you willing to change a nappy?

Upload DBS Documents

📌 You must upload 3 different documents from the allowed list below.

⚠ You cannot use the same document type twice.

❌ Not Allowed Documents:

Duplicate documents (e.g., two passports or two utility bills)
Expired documents
Uncertified copies of documents
Handwritten or unofficial records

Document 1

Document 2

Document 3

Accepted formats: PDF, JPG, JPEG, PNG

Additional Info

Occupation

School

Profile Image

Has Driving License

References

Reference 1 - Name *

Reference 1 - Email *

Reference 1 - Number *

Reference 2 - Name *

Reference 2 - Email *

Reference 2 - Number *

Consent

I agree to my receiving medication as instructed and to any emergency dental, medical or surgical treatment, including anesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand the extent and limitations of the insurance cover provided. I attest to the accuracy of all the information provided.

I confirm that I will keep all information confidential.

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