Work Experience and Work Placement

Application Form

STRICTLY CONFIDENTIAL

YOUR DETAILS
Name:
Date of Birth:
Age on first day of placement:
Home address:
Post code:
Mobile:
Home number:
Email address:
Emergency contact name:
Emergency contact number:
SCHOOL/UNIVERSITY DETAILS
School/College/University:
Address:
Post code:
Phone number:
Teacher/Tutor name:
Teacher/Tutor phone number:
Teacher/Tutor email address:
PLACEMENT DETAILS
Dates work experience placement required:
Qualifications held and/or being studied:
Area you are interested in for work experience:
(please note not all departments are able to host work experience due to the nature of the work, and due to high demand you may not always be able to be placed within your preferred area)

REHABILITATION OF OFFENDERS ACT 1974-amendments order 2002

(IF APPLICANT OVER 18)

The National Health Service is exempt from the provisions of Section 4 (2) of the Rehabilitation of Offenders Act. Under this act you must therefore declareany criminal convictions, even if they are “spent” received either prior to your application for a Work Placement or during it. Failure to disclose such convictions may result in the immediate termination of your work placement.

If appropriate, please state “no convictions to declare”

(or please provide relevant information of convictions below)

Signed: Date:

Please be aware there is a currently a high demand for work experience placements therefore you may not receive a response straight away. We aim to provide a response within approximately 4 weeks.

Thank you for completing the application form, please return to:

Learning and Development, Education and Training Centre, Countess of Chester Hospital NHS Foundation Trust,Liverpool Road,Chester CH2 1ULTel: (01244) 365834

Equal Opportunities Monitoring Form

The Countess of Chester Hospital NHS Foundation Trust is committed to ensuring that applicants are considered for a placement irrespective of gender, sexual orientation, marital or parental status, disability, religion, social class, nationality or ethnic origin.

In order to monitor the effectiveness of our Equal Opportunities Policy, we require applicants to provide the information outlined below. This information is confidential and used solely for monitoring purposes. Such use will be subject to the provision of the Data Protection Act 1998.

1. Personal information
Title / Surname
First names / Date of birth
2. Ethnic Origin (UK applicants only). I would describe myself as:
□ / White / □ / Other Asian background
□ / Gypsy or Traveller / □ / Arab
□ / Black or Black British – Caribbean / □ / Mixed – White and Black Caribbean
□ / Black or Black British – African / □ / Mixed – White and Black African
□ / Other Black background / □ / Mixed – White and Asian
□ / Chinese / □ / Other Mixed background
□ / Asian or Asian British - Pakistani / □ / Other Ethnic Background
□ / Asian or Asian British - Bangladeshi / □ / Not known
□ / Asian or Asian British - Indian / □ / Information refused
3. Disability. I would describe myself as:
□ / No disability
□ / Social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
□ / Blind or have a serious visual impairment uncorrected by glasses
□ / Deaf or a serious hearing impairment
□ / A long standing illness or health condition such as cancer, HIV diabetes, chronic heart disease or epilepsy
□ / A mental health condition such as depression, schizophrenia or anxiety disorder
□ / A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
□ / A physical impairment or mobility issue such as difficulty using arms or using a wheelchair or crutches
□ / A disability, impairment or medical condition that is not listed
□ / Two or more impairments and/or disabling medical conditions
Please list any reasonable adjustments you think you may require: