1. PERSONAL DETAILS

Surname: / First Name:
Home Address: / Contact Number:
Email Address:
Age:
Postcode: / Date of Birth:
Name of School/College/University:
Current courses being followed (e.g. GCSEs/A levels etc.):
Career aspirations:

APPLICATION FORM FOR WORK EXPERIENCE

  1. PLACEMENT DETAILS

I would like to undertake a work experience placement on the following date:
(please tick as appropriate)
19-23 February 2018
12-16 March 2018
9-13 April 2018
25-29 June 2018
16-20 July 2018
22-26 October 2018
I would like to undertake my work experience placement in the following area:
(please tick as appropriate)
Catering Department / Ward Based (health care)
Administrative / Finance Department
Medical Taster (16+) / X Ray Porters
Research (16+) / Pharmacy (university students only)
Physiotherapy (two day placements 16+)
*not restricted by the above dates. Dates can be accommodated by request / Occupational Therapy (one day placement 16+)
*not restricted by the above dates. Dates can be accommodated by request
  1. IN THE EVENT A PLACEMENT IS NOT AVAILABLE

It is not always possible to provide every student who applies for work experience with a placement. We can however attempt to make alternative arrangements at another trust within Shropshire.
Please try to make me alternative arrangements if necessary (please circle) YES / NO
I am prepared to travel ______miles from my home address.
  1. REFERENCE

TO BE COMPLETED BY SCHOOL TUTOR
Please comment on students suitability for the placement requested. Particular consideration should be given for requests in areas where there is access to children and vulnerable adults. By signing you are also confirming that the information given in this application is, to the best of your knowledge, accurate.
______
______
Signed: ______Please print name: ______
  1. DISABILITIES

Do you have any health condition, disability or learning needs that we should be aware of? YES / NO
IF YES, please provide details: ______
______
  1. DECLARATION

You have the responsibility to acquaint yourself with the safety rules of the work place, to follow these rules and make use of the facilities and equipment provided for your safety. It is essential that all accidents are reported.
You must follow all rules and regulations of the Trust, and note that there is a No Smoking Policy throughout the entire working environment.
The Trust fully supports equal opportunities in employment and opposes all forms of unlawful or unfair discrimination.
There will be no payment for meals or travelling expenses.
I have read and understood the above requirements. I understand that if offered a placement, it will be subject to the information given on this form. I agree to work with departmental guidelines and follow instructions given.
Signed: ______Date:______
*FOR STUDENTS UNDER 18 YEARS OF AGE:
Parent/Guardian
I give permission for my son/daughter to attend a placement at the RJAH Orthopaedic Hospital NHS Foundation Trust.
Signed: ______Date: ______
  1. EQUAL OPPORTUNITIES MONITORING INFORMATION

Gender: Male  Female  / Marital Status: Married  Single  Divorced 
Separated  Widowed 
Ethnic Origin: Please note we are not asking about citizenship or nationality, but the ethnic group to which you feel you belong. Choose one section from (1) to (5) then tick one box.
(1)WHITE
British
Irish
Any other White Background (specify) ______
(2)MIXED
White and Black Caribbean
White and Black African 
White and Asian
Any other mixed background (specify) ______
(3)ASIAN OR ASIAN BRITISH
Indian
Pakistani
Bangladeshi
Any other Asian background (specify) ______
(4)BLACK OR BLACK BRITISH
Caribbean
African
Any other Black background (specify) ______
(5)OTHER ETHNIC GROUP
Chinese
Any other (specify) ______

PLEASE RETURN THIS COMPLETED APPLICATION FORM TO:

Allen Edwards
Human Resources Department
RJAH Orthopaedic Hospital NHS Trust
Oswestry
SHROPSHIRE
SY10 7AG