EXIT

Work Experience Placement

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* 1. Contact Details

Name

Address

Address 2

City/Town

County

Post Code

Email Address

Phone Number

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* 2. Preferred Area for Work Experience

Clinical (eg Patient Wards, Theatres, Surgeries, Radiology)

Non Clinical (eg Medical Admin, Office Admin, Finance, HR)

Other (eg Maintenance)

If you have a preferred specialist area please add in the comments box and we will try and accommodate this.

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* 3. Dates you are available (Please give as many as possible)

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* 4. The RNOH prides itself on offering equal opportunities to all. To that end we respectfully ask that you complete the following information.
Under the terms of the Equality Act 2010 a disability is defined as a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities. We welcome applications from people with disabilities.

Do you have a declared disability? (If so please give full details)

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* 5. Please advise your date of birth

Date / Time

Date

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* 6. Please describe your gender

Male

Female

Other

Do not wish to disclose

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* 7. Please describe your ethnicity / race

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* 8. Do you have an infectious disease which may affect others (if yes please give details)

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* 9. Next of Kin / emergency contact details

Full Name

Relationship to you

Address

Postcode

Telephone Number

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* 10. Supporting Information
This is your opportunity to promote yourself, to identify why you would like to gain some work experience in the NHS. Please use this space to provide any supporting information to go with your application. Supporting information can be anything that is not already covered and may include any hobbies, interests or other activities either within or outside school / college, which you enjoy.

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* 11. School / College details

School/College Name:

Address:

Postcode:

Form Tutor / Career Advisor (For reference Purposes)

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* 12. Previous Work Experience
Please enter in the boxes below previous organisations that you have undertaken work experience at and also add details of the activities undertaken.

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* 13. I declare that the information in this questionnaire is correct

Yes - The information is compete and accurate

No - I have missed out information that is relevant to my application

Please explain why you have left out information

Thank you for completing our on-line application process for Work Experience. Your application will be reviewed and will be acknowledged within 4 weeks. If you are successful in being allocated a position, full details will then be confirmed within one month of your placement.

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* 1. Contact Details

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* 2. Preferred Area for Work Experience

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* 3. Dates you are available (Please give as many as possible)

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* 5. Please advise your date of birth

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* 6. Please describe your gender

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* 7. Please describe your ethnicity / race

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* 8. Do you have an infectious disease which may affect others (if yes please give details)

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* 9. Next of Kin / emergency contact details

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* 11. School / College details

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* 12. Previous Work ExperiencePlease enter in the boxes below previous organisations that you have undertaken work experience at and also add details of the activities undertaken.

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* 13. I declare that the information in this questionnaire is correct

* 12. Previous Work Experience
Please enter in the boxes below previous organisations that you have undertaken work experience at and also add details of the activities undertaken.