Work Experience Application Form Essay example

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APPLICATION FORM FOR WORK EXPERIENCE PLACEMENT
1.

PERSONAL DETAILS

Family Name:…………………………………………………………………. First Name: …………………………………………
Home address: …………………………………………………..………………………………………………………………………
…………………………………………………..…………………………………………………………………………………………
Tel No …………………………………………………Post Code: …………………….. email address:…………………………………………………………. May we contact you using this? Yes/No
Age: ………………………………………………………. Date of Birth: ……………………………………………………………
Emergency contact (Name)………………………………………………..Day time Tel No: ……………………………………….
Have you previously had any work experience at either hospital site within the Trust? Yes/No
If so, which site and department? ……………………………………………………………………………………………………
Name and address of School/College/University: …………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………...
Current details of courses being followed (eg GCSE’s/A Level’s etc) ……………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
Career aspirations:……………………………………………………………………………………………………………………….
2.

PLACEMENT DETAILS:

Date(s) placement required: ……………………………………………………………………………………………………………
I would like to do my work experience placement in the following department & Hospital (please tick an area & Hospital - if you

would be able to work in either Hospital please tick both boxes and send to only one of the named contacts - they will then discuss who can best accommodate your application):

Administration:

Clinical Audit
Clinical Governance
Information Technology
Library
Medical Records
Medical Secretaries
Medical Staffing
Human Resources
Development & Training
Switchboard
Waiting List office

Audiology
Cardio-Respiratory
Catering
Dental Nurse
Dietetics
Heart Assessment Team
Nursing
Occupational Therapy
Orthoptics
Pharmacy
Physiotherapy
Plaster Room

Portering
Shadowing a Doctor
Speech & Language Therapist
X-ray/Radiographer

PRINCESS ROYAL HOSPITAL
TELFORD
ROYAL SHREWSBURY
HOSPITAL

IN ORDER TO ENSURE SUFFICIENT NOTICE IS AVAILABLE FOR YOUR PLACEMENT TO BE ARRANGED, IT IS
IMPORTANT THAT THIS APPLICATION FORM IS RETURNED
DIRECTLY TO THE CONTACT PERSON NAMED ON THE FORM FOR THE DEPARTMENT/S OF YOUR CHOICE

3.

SPECIAL NEEDS

Do you have any health condition, disability or learning needs that we should be aware of?

Yes/No

If so, please give details:
……………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………...

4.

REFERENCE

TO BE COMPLETED BY WORK EXPERIENCE CO-ORDINATOR/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 contained in this application is, to the best of your knowledge, accurate.
……………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………...
Signature: ……………………………………………………………. Please print name:
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