Work Experience

Personal Information

Full name: Required

Are you over the age of 16? Required

Yes

Home address Required

Address 1

Address 2

City

Country

County

Postal Code

Mobile number: Required

Home number:

Email address: Required

School or College currently attending (if applicable): Required

School or College phone number (if applicable):

Contact Teacher/Tutor name (if applicable):

Placement Request Details

Date(s) placement/work experience required Required

Placement/work experience area required: Required

GCSEs and other qualifications (including grades) already obtained: Required

Current Studies: Required

Are you planning to apply for a relevant apprenticeship/ university programme? Required

Yes

If yes, please specify the course:

What would you like to achieve from this placement (please tell us a bit about your future plans and how this placement would help you reach your goals): Required

Personal Statement (please tell us a little bit about yourself, for example previous work experience or hobbies, part time work or regular activities you attend): Required

Reference

Individuals are required to submit a reference supporting your application from either a teacher (if at school), employer or a professional person.

This should include comments on your personality and behaviour, as well as your suitability for the placement/work experience you are applying for.

It needs to be signed with their name, title and signature, as well as stating their relationship to you.

Attach your reference here: Required

Additional information about you

The additional information requested below is to enable us to complete national data auditing processes. Should you not wish to complete any of this information it would not affect the success of your application.

Type of school you attend or attended between 11-16?

Are you eligible for or in receipt of free school meals?

Yes

Prefer not to say

Have you ever been living in local authority care for a period of three months or more?

Yes

Prefer not to say

Are you a registered young carer?

Yes

Prefer not to say

Are you in employment?

Yes

Prefer not to say

If yes, where are you employed?

If not in education, training or employment have you had an extended period of unemployment?

Yes

Prefer not to say

If yes, how long have you had an extended period of unemployment?

Do your parents have a university degree from the UK or abroad?

Yes

Prefer not to say

Do you have a relative(s) working in this Trust?

Yes

Prefer not to say

If yes, please name the department(s) they work in:

Equality Assessment Monitoring

Gender:

Is the gender you identify with the same as your sex registered at birth?

Yes

Sexual Orientation:

Ethnicity:

Data protection statement

All of the information collected in this form is necessary and relevant to the work experience placement. We will use the information provided by you for recruitment purposes and undertaking of the placement only. We will treat all personal information with the utmost confidentiality and in line with current data protection legislation.

Should you be successful in your application, the information provided, and further information that will be gathered at the relevant time, will be subsequently used for the administration of your placement and in relation to any legal challenge which may be made regarding our practices.

Agreement - The Student Required

I have read Chesterfield Royal Hospital NHS Foundation Trust’s Policy on Work Experience and understand that in the course of my placement with the Trust, I may come into contact with, or have access to, confidential information relating

Agreement – Parent / Guardian (if student is aged under 18)

My legal guardian has read Chesterfield Royal Hospital NHS Foundation Trust’s Policy on Work Experience and agrees to this placement.

Previous Convictions

This placement is exempt from the Rehabilitation of Offenders Act 1974 because it involves access to patients. This means that you must provide details of any previous criminal convictions. This information will be kept in confidence and will be discussed at informal interview, only if the conviction is considered relevant to the placement.

Have you any criminal convictions? Required

Yes

If ‘yes', please state the nature of the conviction below:

Declaration Required

I declare that the information I have provided above is correct and complete.

Occupational Health Check

Our 'Occupational Health Check ’is part of our pre-engagement checks. All applicants are required to complete the form and attach it below (you can find the form attached to this page). Required

I agree to the privacy policy

Work Experience Form

Work Experience

Personal Information

Placement Request Details

Reference

Additional information about you

Equality Assessment Monitoring

Data protection statement

Previous Convictions

Occupational Health Check

More information in this section

Work Experience Form

Work Experience

Personal Information

Placement Request Details

Reference

Additional information about you

Equality Assessment Monitoring

Data protection statement

Previous Convictions

Occupational Health Check

More information in this section...

Accessibility tools

More information in this section