Early Chilhood Ireland ae Hainaut House, Been Square South, earl punrvo childhood ireland Form VB Vetting Invitation Under See 26(b) of the National Vetting Bureau (Children and Vulnerable Persons) Acts 2012 t0 2016, its an offence to make a false statement forthe purpose of obtaining a vetting disclosure, reams: OTe [ols [ze O wuaaerome FT fi [etch cle sume: foleT [lets [efal ole [alt Mle lt [ola al Daweor men F276 [Tg fo] [S14 [9 [3 [reenter ctl sle fe]. Jefe ie ematadsress To Lali [ste mA conrersember: [8/3 | 2folofalala[e ie > = fm iP = g im Current Address tine: [BETHEL |e 1 Al Line2: [WIE |S | T]B]U} RY TTT umes: [Clo fefele fe |e vines: [E}i Jw fe [Ref tines: {CHL | aL RE. eircodePostote: (YL 4] aly = = Name OF Orga Thave provided documentation to validate my identity as required and ay/ his form tothe above named organisation. An invitation tothe e-vetting website wil then be ve siaure: [Oinige Piste Vein I Au ue [TT] Note: Your Email addresDocument Nox [Toe Be] Document Tis | Reference Contact Deals a ‘Approved Date! [01/06/2019 Fase In order to progress with your application, we require you to provide us with some key information relating to your reference detalls. We would appreciate if you could provide these contact details promptly to ensure at this stage there Is no delay with progressing your application. Please complete the below table fully before returning with the other documentation in this ema Please note the following ‘You must provide at least 3 reference contacts ensuring that you provide the following Information for each: Name, Place of work, Emil Address, Contact Number, Relationship to you. ‘+ If you have worked previously, we require your most recent employer provide a reference of isa regulatory requirement and is required for you to successfully ‘employment for you. T be offered a role with Busy Kids ‘= If youdo not have employment provider details cry, please provide us with your most recent education Fulnane afeonact [Pacrafwork | Enafaies—) Coieriumbar [aera oye ut | ie, Manager the 2 [Ealenve ack @ biWrorg Toe] a5 Wk] Ouner, Bek Here [EI Bel [ees [065 335 233 | eer % Anne Callirany — |Limerek Sten’ lanm.celiman® | ob) 42] #28 | tloman Ressorces se) leimen Lie wares ape Bea rf, barf Rost = Pitot. [eB [materia ocd 40d 208 [axe Tom | a | | Ifyou have any questions or require further information, please do not hesitate to contact us on (090 6471017,| Applicants should be aware; they do not have to provide the information requested below however al applicants must undergo formal Garda Vetting through the National Vetting Bureau. formation given will test confidence.) Applicat Name: Prize Goth Olivcita de Blmeidn Pree | 26 [40/1993 _| Section 2: Criminal Convictions / Impending Prosecution Information QI. Have you ever been convicted ofa criminal offence? (Including motoring offences, Yes C1 No fd but excluding parking fines) List all convictions in all countries. Ifyou answered “Yes”, please give full details. Continue on a separate sheet of paper if necessary. ‘2. Do you have any court proceedings pending or are you awaiting sentencing by a yes No 2 criminal eourt? If you answered “Yes”, please give full details. Continue on a separate sheet of paper if necessary.[[Q3. Have you ever received a formal Garda and/or Police caution? ‘ Nes Noxt If you answered “Yes”, please give full details. Continue on a separate sheet of paper if necessary, Section 3: Applicant's Declaration TDenite Pisco Clitwira de Plane sda ‘am aware that: a) Ido not have to complete this form, however this will lead to me being excluded from the recruitment process. b) The information I have provided is true and completed to the best of my knowledge. | understand that knowingly providing false information or withholding information may render my application liable to rejection, or, if appointed may make me liable for disciplinary aetion up to and including dismissal ©) I must undergo formal Garda Vetting as part ofthe recruitment process and if I was to receive a criminal record during my employment with Sonas; I must notify my Manager immediately. | 4) If receive a eonvietion or pending convietion during my employment with Sonas; | am required to notify my Manager immediately Applicant's Signature: Y h = Onip. Boia, Qin AMrerd. , 33 fou. 2003 ; |(Document Tae ] Medical Declaration of Finness to Work Template | Document Noz —[ TO21 [Arpoved Date [01062019 eal ae] Applicants should be aware; they do not have to provide the information requested below however this ‘may lead to them being requested to attend an occupational assessment to ascertain their fitness for the position for which they applied. ‘Section 1 ~ Applicant Details (Al! information given will be treated in strictest confidence.) Applicant Name: Tse Gist Cui deAmaseP® Name [p, Fonse He Mahon Postionanplied fs [Coleg Sypcvisae GPs Address [lover Ged Gn gRMPSE Date of Birth: 16 f30(4953 __—_—_—P'sPhoneNor|oyy 343 919 ‘Section 2 - Your Health History Have you ever had any serious | Yes (J No @ I yes, please provide details: illnesses, accidents or surgery that ‘would impact your ability to perform your role? Do you have any health limitations | Yes CI No Of If yes, please provide details: ‘or previous illnesses/aceidents/ surgery which you require support for in order to carry out your new role? Yes (No B Ifyes, please provide details: Are you currently taking any your ability to perform your role? ‘Are you currently vaecinated/immune against the following? Influenza (Flu) __| Yes © No Gl | Hepatitis B (HBV) “Yes No O Pertussis (Whooping Cough) [Yes G2 No Ci | Measles, Mumps & Rubella(MMR) | Yes £1 No 0 Varicella (Chicken Pox) Yes No CI | BCG Vaccine - Tuberculosis (TB) | Yes @ No O Do you have difficulty with/suffer from any of the following? Crouching/bending/kneeling ‘Yes No Gi | Climbing stars/ladder Yes No Walking on uneven ground Yes No Gi | Gripping firmly with both hands | Yes 2 No ‘Turing your head rapidly Yes O.No Bl | Mental Health Disorder Yes (No fl Concentrating on a task Yes No ® | steeping Yes (No Standing for 2 hours or more YesONo fl | Altergies Yes No@ | Sitting for 2 hours or more Yes No & | Breathing Problems eee Back or Neck Problems (Backache, injury, | Y¢S J No 0S | Neurological Disorder (Epilepsy, | Yes No) | sciatic, whiplash coe)? migraines, mule sclerosis rater) Eye Sight or Vision Problems Yes 1 No | Defective Hearing Yes Q1No@ Heart Problems (High/ow blood pressure, | Yes CJ No fil | Fainting, panic attacks, black outs, | Yes No heat disease or other) dizziness, seizures | | Diabetes Yes ONo @ | other Nene ws Other: = iE Page 1of2rove please provide Walls ae OSGI, rier | ‘ppl | LDanize Higdla. Olena de reticle | 4) the information I have provided is true and completed to the best of my knowledge. I understand that knowingly providing false information or withholding information may render my application liable to rejection, or, if appointed may make me liable for disciplinary action up to and including dismissal. 'b) Jam fully aware and understand that itis highly recommended for healthcare workers to be vaccinated and/or immunised against Influenza (Flu), Pertussis (Whooping Cough), Varicella (Chicken Pox), Hepatitis B (HBV), Measles, Mumps & Rubella (MMR) and BCG Vaccine — Tuberculosis (TB). ©) Tam fully aware and understand that | may be requested to attend the company’s Medical Advisor at the ‘company’s expense for further information/clarity regarding my current medical status. aessignature: (nize Cline Drom db Dincic 23 Ing [2023 | Section int’s Deel Page