Health Monitoring Form - Ganaway Activity Centre

Job Applying for:*

Personal Details

Name*

First Last

Height*

cm

Weight*

kg

Medical Details

How would you describe your general state of health?*

Do you suffer from Asthma?*

Yes
No

Please outline how you asthma affects you?*

Do you suffer from Epilepsy?*

Yes
No

Please outline how you epilepsy affects you?*

Do you suffer from Diabetes?*

Yes
No

Please outline how you diabetes affects you?*

Do you have any special dietary needs?*

Yes
No

Any medical reason to prevent you from undertaking strenuous work?*

Yes
No

Please outline medial condition that would prevent you from undertaking strenuous work?*

Any serious recent (with 2 years) of ongoing illness, operation or injury?*

Yes
No

Please give details of any serious recent (with 2 years) of ongoing illness, operation or injury.*

Data Protrection

I consent to the information I have provided in this form being used for:

- Processing my application for this post, including both manual and computerised.
- Records and retaining this information for a period of 12 months after the selection exercise.
- Transfer to my employment record if I am appointed, including both computerised and manual systems after which it will be held for the duration of my employment and for up to 6 years thereafter.

I understand that this information will be processed and sorted in accordance with the Data Protection Act 2018.

Signature*

Date*

Full Name*

Consent*

I understand this is a legal representation of my signature.*

Ganaway Application Form - Health Monitoring

Personal Details

Medical Details

Data Protrection