Therapeutic Residential Support Worker

Gateways Support Services Inc. acknowledges and respects the privacy of individuals. This information is being collected for the purposes of potential employment. The provision of this information is voluntary, but if this information is not provided, Gateways may not be able to assess your application for employment adequately. In signing this document, you are providing your consent for Gateways to contact your nominated referees. The information collected will be held by Gateways and Gateways will take reasonable steps to protect any personal information it holds from misuse, modification, loss or unauthorised access until it is no longer required. At such time that the information is no longer required, Gateways will take reasonable steps to destroy or permanently de-identify the information.

1. Yes I agree to the privacy statement*

1. Title* Mr Mrs Ms Miss Dr Other
2. First name*
3. Last name*

1. E-mail*
2. Phone*

   Digits only or add + for international numbers

1. Street*
2. Street Cont.
3. City, Town or Suburb*
4. Postcode or Zipcode*
5. Country*Please choose... AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BRAZIL BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE INTERNATIONAL OTHER Unknown
6. State, Region or Province*Please choose...

1. LinkedIn URL

   (Please click on your profile and copy the URL from your profile page.)

1. What makes you suited to the role?*
2. Why are you interested in this position? *
3. Are you registered with Jobs Victoria?*

   1. Yes
   2. No
4. Are you registered with a job active organisation? If so, which one?*
5. Current or Previous Employment
   Current Employer Name and Location: *
6. Your Position:*
7. Date from:*
8. Date to:*
9. Current Hours:*
10. Status:*

    1. Full Time
    2. Part Time
    3. Permanent
    4. Temporary
11. Reason for seeking to leave:*
12. Educational Qualifications and Achievements
    Highest Level Achieved:* Year 11 Year 12 Cert III Cert IV Diploma Bachelor
13. Relevant Qualifications:*

    1. Individual Support
    2. Disability Support
    3. Community Services
    4. Other (e.g. Social Work, Youth Work)
    5. Other
14. Do you have any relevant certificates or achievements? (E.g. volunteer appreciations, school achievements, courses completed)
15. Celebrations and things you're proud of - is there anything else that you're proud of achieving that you would like to share with us?
16. Please tick the skills and attributes you currently hold:*

    1. Administrative/Record Keeping
    2. Advocacy
    3. Anaphylaxis Management
    4. Catheter
    5. Child Safe Reporting/Mandatory Reporting
    6. Communication Skills
    7. Computer/Technical Skills
    8. Diabetes Management
    9. Enema and Midazlom Administration
    10. Epilepsy Training
    11. Infection Control
    12. Manual Handling Hoisting
    13. Meal Planning
    14. Medication Administration
    15. Mental Health First Aid
    16. Oxygen Administration
    17. Peg Feeding
    18. Personal Care
    19. Restrictive Practices
    20. Safe Food Handling
    21. Van Wheelchair Life Competency
17. Preferred Hours
    Please indicate your availability:*
18. Are there any times/days that you cannot work?*
19. How many hours per fortnight do you want to work? Please include your minimum and maximum amounts.*
20. Are there any other reasonable workplace adjustments or modifications that you require to perform the requirements of the position?*
21. Are you an Australian citizen or do you have the right to work in Australia?*

    1. Yes
    2. No
22. If you are on a visa, please state the visa subclass and hours permitted to work:
23. An international police check is required for applicants who have lived overseas for 12 months or longer during the past ten years. Is an international police check required?*

    1. Yes
    2. No
24. Do you hold a current Victorian Driver's Licence?*

    1. Yes
    2. No
25. If yes, please state licence number, expiry date and licence type (e.g. car):
26. Have you been convicted of a driving offence?*

    1. Yes
    2. No
27. If yes, please state the details:
28. Do you hold a current CPR certificate?*

    1. Yes
    2. No
    3. Willing to obtain
29. If yes, please state the expiry date:
30. Do you hold a current First Aid Certificate?*

    1. Yes
    2. No
    3. Willing to obtain
31. If yes, please state the expiry date:
32. Are you of Aboriginal or Torres Strait Islander origin?

    1. Yes
    2. No
33. Do you speak a language/s other than English?
34. Do you require reasonable adjustments to complete the selection process?*

    1. Yes
    2. No
35. Health Declaration
    Employment is conditional on being fully able to perform the duties/requirements of the position. The purpose of this declaration is to ensure that no person is placed in an environment/given tasks that will result in physical/mental harm.
    
    We request that you disclose any pre-existing injuries/diseases of which you are aware and could affect the ability to perform the duties of the position. If you fail to disclose or provide misleading evidence of any recurrence, aggravation, acceleration, exacerbation or deterioration of a pre-existing condition you may not be entitled to any compensation under the Workplace Injury Rehabilitation and Compensation Act 2013. Please provide information of any medical history, medication, pre-existing illnesses, diseases, physical or psychological conditions which could affect/be aggravated by the work you are applying for.*
36. Referees
    Please provide two (2) referees, who can be contacted in relation to your experience and performance.
    
    Name:*
37. Organisation and Position:*
38. Phone:*
39. Name:*
40. Organisation and Position:*
41. Phone:*
42. I declare that the information in this Form is true and correct and consent to any reference checks which may be necessary to support this application.
    
    If my application is successful, I agree to be bound by Gateway's Conditions of Employment. Should it be proven that any responses to this application are incorrect or I have breached the Conditions of Employment I will accept Gateways right to terminate my employment.
    
    I have read and acknowledge and agree to abide by Gateways Policies, Procedures and Instructions as provided.*

    1. Yes
    2. No