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Please print off this form, complete all of the sections below giving dates and full details where appropriate and then upload it onto your Kings Recruit Profile in the Qualifications section with your other required certificates.
| Title: / Mrs / Miss / Ms / Other (circle as appropriate) | ||||||||
| Surname | Forename | |||||||
| Home Address | ||||||||
| Post CodeHome Tel No. | ||||||||
| Position: Site Manager/ Activities Manager/ Swimming Coach/ Teen Coach/ Play Leader/ Multi Sports Coach/ Kids Camp Coach/Assistant Coach/Work Placement/Soccer Coach/Assistant Soccer Coach/Cricket Coach/ Assistant Cricket Coach (circle as appropriate) | ||||||||
| Are you in good health at the present time? | ||||||||
| If you answer ‘No’ please give details(continue on a separate sheet if necessary) | ||||||||
| Are you at present attending a doctor or hospital for any reason? | ||||||||
| If you answer ‘Yes’ please give details (continue on a separate sheet if necessary) | ||||||||
| Are you taking any medicine or tablets or having any other treatment regularlyprescribed by a doctor or hospital? | ||||||||
| If you answer ‘Yes’ please give details (continue on a separate sheet if necessary) | ||||||||
| Have you now or in the past had any disease or complaint, other than normalchildhood illnesses, colds and flu? | ||||||||
| If you answer ‘Yes’ please give details including dates (continue on a separate sheet if necessary) | ||||||||
| Have you ever had any of the following: | ||||||||
| Depression or similar illness | Thrombosis | |||||||
| Tuberculosis | Contact with anyone who has Tuberculosis | |||||||
| Diabetes | Problems with mobility | |||||||
| Back problems | Heart Problems | |||||||
| Blackouts, epilepsy, fits or faints | Have you been admitted to hospital in thelast two years or have you suffered anyserious illness in the last five years? | |||||||
| If you answer ‘Yes’ to any of the above please give details (continue on a separate sheet if necessary) | ||||||||
| I declare that the particulars I have given on this application form are true in every respect. I also agree to notify King’s Camps of any changes that may necessitate the completion of a further declaration | ||||||||
Signed |
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