ÐÏà¡±á>þÿ :<þÿÿÿ9ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á#` ð¿/bjbj\.\. 2&>D>D.ÿÿÿÿÿÿ¤4444¨¨¨¼@@@@L$¼}î|||||¿¿¿üþþþþþþ$khÓR"¨D@¿DD"44||7ÈÈÈDR4R|¨|üÈDüÈÈ†"¨È|p0ðÍá€@Ç@–úÈèM0}È%%È%¨È ¿Z@ÈY4·¿¿¿""¬¿¿¿}DDDD¼¼¼„ @¼¼¼@¼¼¼444444ÿÿÿÿ1. APPLICATION FOR LIVING WITH THE ELDERLY Name of the applicant _______________________________________________________________ Date of birth _____________________________ Age ___________________________ Religion _________________________________ Nationality ____________________________ Father’s occupation ______________________________________________________________ Mother’s occupation ______________________________________________________________ Brother(s) _______________________________ Age(s) ___________________________________ Sister(s) ________________________________ Age(s) _______________________________ Present occupation _______________________ Profession _____________________________ Have you ever had any criminal convictions? __________________________________ Education (name of your present or last school) ______________________________________________ Describe your experience in care of elderly: __________________________________________________ ______________________________________________________________________________________ Are you a trained nurse?__________________________________________________________________ ( If yes, state your qualification and attach your certificates) Which level of nursing have you obtained?____________________________________________________ Do you wish to further your career by working in a UK hospital?___________________________________ Have you cared for an elderly person a) home______________b) only in a hospital situation ___________ Are you confident to take sole responsibility for an elderly person?_________________________________ Will you need to have the back-up of caring relatives?___________________________________________ Are you used to the housework? ________ Washing? ________ Ironing? __________ Cleaning? _________ Do you accept person with: Mobility difficulties_______Mental difficulties_______Special cooking_________ Can you help with cooking? ___________________ Can you cook? ________________________________ Knowledge of English: ______________ Basic / Lower Intermediate / Upper Intermediate / Good How long have you been studying English? ___________________________________________________ Any other languages? ____________________________________________________________________ What are your hobbies and interests? _______________________________________________________ ______________________________________________________________________________________ Do you smoke? _________ Are you prepared not to smoke in your host family’s home? ________________ Do you drive? ______ Since when? ___________________ Can you drive in England? (choose a,b,c or d): a) immediately _____ b) after a little training ____ c) after a lot of training _____ d) not willing to drive ___ Do you like animals? _____________________________________________________________________ Do you have a valid passport? _______________ Passport number: _______________________________ Do you have any physical disability? __________________________ Can you swim? __________________ General state of health: ________________________ Height: _____________ Weight: ______________ Have you lived abroad before? (Describe) ____________________________________________________ ______________________________________________________________________________________ When do you wish to start? _________________________________________________ How long do you wish to stay? ______________________________________________ I have read, understood and agree to the conditions contained in the enclosed leaflet and confirm that the information given here is true. Signature ________________________________________ Date __________________________________ PLEASE CONTINUE ON PAGE 2 2. 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