Work Experience Application Form

Work Experience Application Form Student Details: First name Last Name Date of Birth Age at start of Placement Address (including postcode) Email ad...
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Work Experience Application Form Student Details: First name Last Name Date of Birth

Age at start of Placement

Address (including postcode) Email address School / College Emergency Contact Details

Clearly state which placement you are applying for and reasons for choosing it

Clearly state which week (date) you would like a placement eg 18/8/14 Interest/hobbies:

Emergency Contact Name

Emergency Telephone Number

Tutor Details: Contact Name & Address:

Phone number: Email address: State reasons why this placement is suitable for the student.

State curricular strengths to support this application (For medical school applicants only: include grades predicted/achieved for A levels)

Any issues the placement provider needs to be aware of?

Where did you source this application form from?

Please indicate below by marking with an X or where you sourced the form.

Direct from an NHS contact NHS website School work experience coordinator Another source – please specify

Why are you looking for work experience? (Delete all not applicable)

Access to Higher Education Unsure of future career Educational requirement Other (please state)

Have you been or considered being a Volunteer at YES Blackpool Teaching Hospitals NHS Foundation Trust?

NO

Monitoring Information (This information will be kept strictly confidential) Blackpool Teaching Hospitals NHS Foundation Trust is committed to promoting equality and diversity within its workforce. It is the wish of the Trust that no person as an employee, applicant or volunteer is discriminated against on the grounds of race, colour, nationality, ethnic origin, gender, religion, marital status, sexual orientation, responsibility for dependants, age, part-time employment, political beliefs or disability. In order to make sure that the Trust’s Equality and Diversity Policy is as effective as possible we need to gather information about people who volunteer for us. This information will not be used for any other purpose than for monitoring of purposes.

Please tick as appropriate Are you? Female Male Are you living in the gender assigned to you at Prefer not to say birth?

No

Yes

How would you describe your ethnic origin? White: British Irish Any Other White Background Black or Black British: African Caribbean Any Other Black Background Asian or Asian British: Indian Pakistani Bangladeshi Any Other Asian Background Mixed White and Black White and Black White and Asian Any Other Mixed Background African Caribbean Chinese Any Other Ethnic Group Unknown Are you disabled? Yes No If yes, how would you describe your disability? Are there any arrangements/reasonable adjustments which we can make for you to help you undertake your work experience placement? If yes, please specify (e.g. ground floor placement, sign interpreter, wheel chair access, school support or any other special educational needs)

Please carefully read the criteria below and sign:         

I normally reside at an FY1 – 8, PR4 or LA postcode and eligible to apply for a work experience placement I confirm I have attained the specified age criteria set by the department to which I wish to apply I understand the application process can take up to six weeks and have therefore allowed sufficient time for my application to be processed I accept that I can only submit one application at a time to be processed I will ensure the application form is filled in correctly, providing sufficient information as well as clearly identifying which department I wish to apply for and the dates that I wish to undertake work experience I understand I should obtain documentary evidence of my vaccinations from my GP. Failure to do so may lead to a delay in commencement or cancellation of placement. I understand that if the request is declined I am eligible to reapply at a later date or for an alternative department immediately I have provided a valid email address that is regularly accessed and I will provide timely responses when required I understand that failure to comply with set conditions or to provide adequate information may result in my application being declined or an arranged placement being withdrawn. I have read and understood the above criteria.

Signed:

Date:

For placement Students under 18 years (Parent/Guardian) I have read and understood the above criteria. I will ensure the student carries out these obligations and confirm that he/she is not suffering from any complaint which might create a hazard to him/her or to those working with him/her. I give permission for my son/daughter to take part in work experience at Blackpool Teaching Hospitals NHS Foundation Trust.

Signed: ________________________________________ Date:

This form should be returned either by post or email (scanned) to: Michelle Pearson Work Experience Coordinator Learning & Development Blackpool Teaching Hospitals NHS Foundation Trust 42 Whinney Heys Road Blackpool Lancashire FY3 8NR Email: [email protected]

Work Experience Health Assessment Form To be completed by a work experience applicant Surname ........................................................ First names.............................................................. Maiden or previous name ..................................................... Male / Female ................................. Title (Dr / Mr. / Mrs / Ms / Miss) ................... Date of Birth............................................................ Address ........................................................................................................................................... ........................................................................................................................................................ Daytime telephone ................................................... Mobile……………………………………. Email address ……………………………………… General Practitioner (Name & Address) ......................................................................................... ………………………… Length and Date of placement ………………………………………………………………………………

VACCINATION HISTORY Have you ever had any of the following vaccinations or tests, please indicate YES, NO or Don’t know. Please give dates and test results where known. Please note you should obtain documentary evidence of any vaccinations you can from your GP (or occupational health department) as this may prevent you having to have blood tests or further vaccination. Please send the original GP report along with this form. Immunisation / Illness

Yes

No

Don’t Know

Date(s)

Test Result

MMR vaccination x 2 Please obtain immunisation report from your GP and attach to this form. Have you had Chicken Pox (the illness) Born in UK If Yes, please state the age in the Date box. Unless you can provide documentary evidence (from your GP) of 2 doses of MMR (Measles, Mumps and Rubella) we will have to test you for this or repeat the vaccination. Do you have a learning disability yes

No

Please complete and submit this form with evidence of your immunity (as above) 6 weeks prior to commencement of work experience placement. Failure to do so may lead to a delay in commencement.

Declaration I declare that all of the statements and information I have made on this questionnaire are true to the best of my knowledge. I understand that giving false information or failing to disclose any significant information could result in loss of your work experience placement.

Signed

Parent/Guardian signature of confirmation of above declaration.

Date