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Personal Details

First Name *

Last Name *

Email Address *

Mobile Number *

Do you currently work for us? *

Upload your CV *

Address Information

Street Address *

City *

County *

Country *

Postcode *

Additional Information

Please give a supporting statement detailing how you meet the essential criteria for the role and how you would demonstrate the Derian Values if you were successful in applying for this role (further supporting documents can be uploaded at the end of this section) *

Please tell us why you want to work for Derian House *

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Registered Professionals: Please indicate your professional body and registration number (eg NMC/GMC)

Do you have a current driving licence? * Yes No

Rehabilitation of Offenders Act 1974

Because of the nature of the work for which you are applying the post is exempt from the provisions of this Act. Applicants are not entitled to withhold information about convictions which, for other purposes are ‘spent’ under the provisions of the Act.

In event of employment, failure to disclose any such convictions could result in dismissal or disciplinary action being. Any information given will be treated as confidential and will be considered in relation to an application for positions to which the Exemption Order applies.

Please indicate if you have any relevant spent cautions or convictions. (This information will only be used if you are successful in your application when the relevant DBS check is completed) * Yes No

Asylum Immigration Act 1996

The Asylum and Immigration Act 1996 makes it a criminal offence for us to employ those who do not have permission to live or work in the UK. Applicants will be required to provide documentary evidence of their right to work in the UK if invited for interview.

Do you have the right to live and work in the UK? Yes No

NI Number

Employment of Friends and/Or Relatives

To ensure equitable treatment of all employees, avoid possible conflicts of interest and prevent any perceived partiality during the recruitment / promotion process, Derian House has a policy to prevent the employment of relatives or close friends in certain circumstances. For example relatives or friends shall not work for the same supervisor/manager or in the same team/office/shift.

Please indicate below if you have a friend and/or relative who works for Derian House

Please indicate below if you have a friend and/or relative who uses Derian House Services

Equal Opportunities

We are committed to the fair treatment of our staff, potential staff, regardless of race, gender, religion/belief, sexual orientation, age, pregnancy/maternity, marital or civil partnership status, physical/mental disability, responsibilities for dependants or offending background.

The information you give on this form will help us ensure equality in our services to you. We recognise that you may regard some of this information as personal and we have, therefore, included an option in most questions for ‘prefer not to say’.

All information that we collect in relation to equality and diversity will be treated confidentially in accordance with the Data Protection Act 2018 and will be stored within the Applicant Tracking System. Access to this information will be restricted to staff involved in the processing and monitoring of this data. It will be used to provide statistical information only. In completing the form below, you consent to us using your data for this purpose.

To which gender identity do you most identify?

What is your age range?

Relationship Status

What is your nationality?

What is your ethnicity? (Please choose the most appropriate option to indicate your cultural background)

Other (please specify)

What is your religion or belief?

Other (please specify)

Do you consider yourself to have a disability as defined in the Equality Act 2010?

If you have a medical condition, the Equality Act 2010 requires employers to make reasonable adjustments to the job content or working environment. To achieve this, we need to know whether you are covered. Definition of Disability: “A physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out normal day-to-day activities in a non-work environment.”

What is your sexual orientation? (As defined in the Equality Act 2010)

Other (please specify)

Pregnancy and Maternity: Maternity is defined in the Equality Act 2010 as the 26 weeks after giving birth. Please select the option which describes your circumstance:

There are 6 million carers in the United Kingdom and nearly one in eight workers are carers. With an ageing population and an expected increase of 60% of carers in the next 30 years, we would like to monitor the number of people with caring responsibilities.

Do you have caring responsibilities?

Other (please specify)

About My Application

I confirm I have the right to work in the UK
I confirm that my details are complete and correct
I confirm I have read and agree to Derian House Children's Hospice privacy policy