SECTION 1: Personal Details

Surname:

Forenames:

Preferred title:

Address:

Postal town: / Post code:
Telephone
(home)
/ Telephone:
(mobile)
Date of birth: / (dd mm yyyy)

Email address:

We will mostly use email to contact you so the email address that you choose to use should be current and valid. Please retype the same address below to ensure accuracy.

Retype email address:

How many days would you like your placement to last for? Days (Max. 5)

Optional Placement Dates:

1. / Start:
/ Finish:
2. / Start:
/ Finish:
3. / Start:
/ Finish:

Which department are you interested in:

SECTION 2: School & Education Details

Name of school/college/university:

If still in school, which year are you in?

Address:


Postal Code:
/ Telephone:

My GCSE or equivalent grades:

Please specify if these results are predicted or actual:

Subject / Type (e.g. GCSE/NVQ) / Grade

My A-Level or equivalent grades (fill in if applicable)

Subject / Type (e.g. GCSE/NVQ) / Grade

My higher education degree or equivalent grade (fill in if applicable)

Please specify if these results are predicted or actual:

Subject:

Type: (e.g. BA/MA/MSc)
/ Grade:

In 500 words or less please give details of any interests or activities that you feel may support your application. Please include details of what you hope to achieve through undertaking this work experience.

Do you believe yourself to have special needs or a disability?

This information is sought under the Equality Act 2010 and enables us to ensure we comply with the act and our internal equal opportunities policies.

If Yes, please give further details:

Do you accept the Terms & Conditions of the programme as outlined in the text above?

2. Do you confirm that you understand that any cost incurred from undertaking a placement will not be refunded by the Leeds Teaching Hospitals NHS Trust and that the location of the placement could be at any of the six hospitals located in the Leeds area?

3. Do you confirm that you understand the date selection process for placements and that failure to turn up on the specified dates, without sufficient reason, will result in the loss of your placement?

4. Do you confirm that all of the information that you have entered on this application is true and that during your placement you will abide by Trust policies on confidentiality and behaviour in the workplace?

Thank you for taking the time to complete this application.

P:\Management\Cardio-Respiratory Team\Work Experience\Documents for work placements\-Work Experience Application Form.doc

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