Please enable JavaScript in your browser to complete this form. good you Adults Please select your nearest branch * Doncaster Healthcare (DNCH)Midlands Healthcare (MIHC)North East Healthcare (NOEH)Yorkshire & East Midlands Healthcare (YEMH)Name *FirstLastPrevious name(s) known byFirstLastTitle MrMrsMissMsAddressAddress Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryMobileTelephoneEmailNational Insurance NoDECLARATION: Please read the guidance notes before answering the declaration and circle the appropriate statement. 1. Do you have any convictions, cautions, reprimands or Final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (exceptions) Order 1975 (as amended in 2013)?YesNo2. Have you ever been, barred, excluded or prevented from working with Children or Vulnerable Adults in the course of any employment, regulated activity, as defined by the Safeguarding Vulnerable Groups Act 2006, whether paid or unpaid?YesNo3. Have you ever been suspended from any professional practice, or subject to any suspension order by any local authority, professional body, inspectorate or similar licensing/registration authority, which may reasonably be regarded as preventing you from working with Children or Vulnerable Adults?YesNo4. Have you ever been subject to or is there any current disciplinary employment finding against you and/or are you currently the subject of an employer’s disciplinary investigation?YesNo5. Do you know of any reason or circumstances that would prevent you from working with Children or Vulnerable Adults in any regulated activity, including any disqualification under the Childcare (Disqualification) Regulations 2018, or is there any other information the company should know about which may have a bearing upon your suitability to work with the vulnerable?YesNoIf you answered YES to any of the above, please supply full details, including if appropriate details of the offence with the date, name of court or constabulary, sentence, outcome, charge and any other relevant information including the circumstances of the conviction and/or suspension.6. Have you, during the past five years, spent any time living or working overseas? (Note: You should indicate ‘YES’ if you spent anytime residing overseas on either a permanent, semi- permanent or temporary basis e.g. through work, an overseas placement or as a foreign national. Time spent overseas as part of an annual holiday should not be regarded as residing overseas for these purposes.)YesNoIf you answered YES to the above, please provide a detailed list of the dates and countries where you resided overseas. You must also provide a certificate of good conduct from the relevant agency for each overseas country in which you resided.Submit