Work Experience Placement Request Form 2017

Please note that completing an application form does not guarantee you a placement, if you are successful in gaining a placement it will be subject to you completing the health assessment.

Personal Details

Title: / Forenames: / Surname:
Address:
Post Code: / Email:
Date of Birth: / Age: / School Year:
Tel number: / Mobile:
Area of interest:
School [ ]
College [ ]
University [ ] / Name: / Course you are undertaking:
Available dates for Placement: / From:
From:
From: / To:
To:
To:
Name of emergency contact: / Emergency contact number:
Name of next of Kin: / Relationship:
Next of Kin contact number:

Please give details of your most recent qualification(s), (gcse, a Level, College courses, diploma, degree or any other courses undertake?)

Subjects:
/ Qualification Grade/Level (received or predicted) / Year of Qualification

Previous NHS Work Experience

Employers Details / Dates from/to / Job Description/duties undertaken

1. Please give an explanation why you have chosen to apply for work experience in NHS:

______

2. Please write a short personal statement explaining why you have applied for work experience and what expectations you have. (Please think about what you hope to gain and how you plan on achieving this) ______

3. Is there any other information you would like us to have in support of your application (Please let us know about any voluntary work or activities that you are involved in)?

Ethnic Origin (please select a number from the box opposite)
Gender (Male or Female)
Do you consider yourself to have a disability (Yes or No)
If you have answered yes to the above, please indicate what disability you have: ______
______

To help us monitor the effectiveness of our Equal Opportunities Policy, and for no other reason, we would be grateful if you could fill in the following details:

ASIAN / 1
ASIAN BRITISH / 2
BLACK / 3
BLACK BRITISH / 4
CHINESE / 5
MIXED / 6
WHITE / 7
OTHER / 8

Please sign this form indicating that you understand and accept the above conditions.

Candidate’s Signature: ______Date: ______

Parent’s Signature: ______Date: ______

If candidate is under 18 years