Personal Assistant Application Form Submission 

Title (required):. 
First Name (required): 
Last Name (required):  
Address 1 (required): 
Address 2: 
Town (required): Treorchy 
County (required): RCT 
Postcode (required):  
Phone number (required): 
Please enter your email address for submission confirmation. (required): 
Reference number of job being applied for (required):
I confirm that I have the right to work in the UK and am able to prove my eligibility status when required to do so. (required): Yes 
Please read the Job Description carefully before providing information in this Section of the Application Form. Give details of your previous employment or experience which you think would help you to do this job. (required): I have 25 years experience as a community mental health nurse. I worked predominantly with people over the age of 65 with dementia including those diagnosed with Lewy Body. I took early retirement in 2011 to look after my elderly mother who was diagnosed with vascular dementia. I recognise how important it is to not only support a patient who has been diagnosed with dementia but also support the family in dealing with such a devastating diagnosis. 
What qualities do you think are important when working as a personal assistant with a disabled person? (required): Good communication skills both verbal and non-verbal. Patience Reliable Trustworthy Non judgmental 
How do you think you can contribute towards the needs and the independence of a disabled person? (required): I think I have a very good understanding of dementia having worked in the health service for over 25 years the majority of which was spent working with people over the age of 65. 
What is it about PA work which appeals to you? (required): I am only looking for part time work in an area which interests me. 
What are your hobbies/interests?:I like to drive, travel and spend time with my grandson 
Would you consider a casual position if you are unsuccessful with this job? (required): Yes 
Do you drive? (required): Yes 
Are you a vehicle owner?  (required): Yes 
Do you smoke? (required): No 
Are you able to undertake training? (required): Yes 
What days/nights are you able to work, or prefer to work?  (required): 1 night sit and possibly 1–2 afternoon sits. 
Are there any circumstances which would prevent you from providing cover or swapping a shift? (required): No 
If you would like to expand on the answers given above? Please use the box below.: 
Name (required)
In what capacity do you know this person (should not be a family member)?  (required) 
In what capacity do you know this person (should not be a family member)?  (required):  
Is there is any such information you wish to disclose, relating to any cautions or convictions which will appear on your mandatory DBS check? (required): No/ 
Please provide details if necessary: 
I agree that there is nothing which would prevent me from doing this job. (required): Yes 
I consent to the above (required): Yes 
I agree that the information I provide will be posted to the Dewis CIL PA noticeboard (all personal information will be withheld).: Yes 
What geographical area’s are you able to cover?: RCT 
How many hours of work can you offer per week?: Max 15 
Please indicate the approximate times that you are available for work throughout the week.: Tuesday Overnight/Wednesday PM/Friday Overnight/Saturday Overnight/Sunday PM / 
Further Information: