- 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
- 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
- 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.
- 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: ______
- DISABILITIES
Do you have any health condition, disability or learning needs that we should be aware of? YES / NO
IF YES, please provide details: ______
______
- 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: ______
- 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 EdwardsHuman Resources Department
RJAH Orthopaedic Hospital NHS Trust
Oswestry
SHROPSHIRE
SY10 7AG