Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you legally entitled to work in New Zealand *

Yes

No

As.. *

A New Zealand Citizen

A Permanent Resident

Work Visa

Working Holiday Visa

Current Work Permit Issue Date

MM

DD

YYYY

Current Work Permit Expiry Date

MM

DD

YYYY

1. Have you ever been treated or hospitalized for a mental illness or condition that would have affected your ability to carry out fully the functions and responsibilities of the position applied for? *

Yes

No

2. Have you had any condition, problems, injury, illness, disability or condition that would have affected your ability in the past or may affect your ability to carry out fully the functions and responsibilities of the position applied for? *

Yes

No

3. Are you on any medication or under any medical treatment or regularly ingest any substances that may affect your ability to carry out fully the functions and responsibilities of the position applied for? *

Yes

No

4. Have you suffered a back injury? *

Yes

No

5. Have you ever suffered from any injury requiring time off work? *

Yes

No

6. Have you ever claimed accident compensation? *

Yes

No

7. Are you suffering from any infectious disease or have any condition which is capable of being passed on to children and is likely to have a detrimental effect if passed onto them [Regulation 31(2)]? *

Yes

No

Have you had the Covid-19 vaccine? *

Note: You will need to provide proof of your vaccination. Only fully vaccinated staff are entitled to work at childcare centres in NZ.

Yes - Fully vaccinated

No

Other

8. Do you smoke? *

Yes

No

9. Do you have any physical or other conditions that would make it DIFFICULT for you to: *

Please tick those that are relevant.

Hear a child from 6 meters away

Sit of the floor without support

Move very quickly

Be on your feet for several hours

See a child from 6 meters away

Pick up a child

Pick up toys or equipment from the floor

Be outside for more than two hours

None of the above

1. Do you have NZ Teacher Registration? *

Yes

No

3. Can you hold an everyday conversation in any language other than English? *

Yes

No

If your application for employment was successful - when could you commence employment? *

MM

DD

YYYY

Retaining Application Consent *

Do you consent to Gems retaining the information contained in this application form for the purposes of considering your suitability for any other position which may arise with this Company in the future?

Yes

No

Reference Consent *

In submitting this application I consent to Gems seeking verbal or written information on a confidential basis about me from representatives of my previous employers, training providers and/or referees and authorise the information sought to be released by them to Gems for the purpose of ascertaining my suitability for the position for which I am applying. I understand the information received by Gems is supplied in confidence as evaluative material and will not be disclosed to me.

I agree

I do not agree

Criminal Conviction History *

Have you ever been convicted of a criminal offence or do you know of any reason why the police might consider you a risk to children as an employee?

Yes

No

Police Check Consent *

I consent to Gems seeking a Police Check of my Criminal Conviction History.

I consent

I do not consent

Declaration *

I declare that to the best of my knowledge the information provided in this application and in any resume enclosed is accurate and understand that if any false or misleading information is givem, or any material fact suppressed, I will not be employed, or if I am employed, my employment will be terminated.

I agree

I do not agree