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Application Form

APPLICATION FORM FOR WORK EXPERIENCE

Please complete this form as fully as possible. If you are unable to complete this form through a reason relating to disability or any other reason, please contact the Work Experience Co-ordinator.

PERSONAL DETAILS:

Title*
Surname:*
Forenames:*
Date of Birth *
Address:*
Post Code*
Contact Number*
Preferred Contact Method:
E-mail:*

Select education establishment: (if applicable)	School College University Other
Name of educational establishment:
Name of course *(if applicable):*
Address:
Post Code:
Telephone:
Contact Teacher/Tutor:
Telephone: (no spaces)

Date of Work Experience	Week commencing:
1st Choice*
2nd Choice*

Placement areas
Choice 1:*
Choice 2:*
Choice 3:*

Please give a brief description of why you would like your work experience to take place at Queens Hospital Burton:*

Any other information:

Please give details of who we can contact in an emergency:*
Contact
If other has been selected above please state relationship

*Emergency Contact Number:

Data Protection

Information given on this application form pertaining to criminal record and physical or mental health conditions/disability is considered sensitive data under the Data Protection Act 1998.

Rehabilitation of Offenders Act

Because of the nature of the work, posts within the National Health Services are exempt from the Rehabilitation of Offenders Act 1974. You are therefore required to declare any pending prosecutions or convictions you may have, even if they would otherwise be regarded as ‘spent’ under the Act, and any cautions or bind-overs.

Having a police record will not prevent students from being considered for placements with the Trust. Offences will be considered in relation to their nature and seriousness in terms of the areas they will be placed in. The information given will be treated in confidence. Failure to disclose relevant information may result in immediate cancellation of the placement.

Do you have any convictions, cautions, bind-overs or charges pending?* Yes No

Nature of Offence	Place/date of judgements	Sentences

Declaration of Confidentiality

I hereby declare to hold in strict confidence, any personal information concerning patients which may become known to me during work experience in any of the establishments of the Burton Hospitals NHS Trust, and that I will not divulge such information to any unauthorised person.

Click here to agree to the Declaration of Confidentiality*

Equal Opportunities

The Trust has a policy of promoting equal opportunities. In order to ensure that this policy is being implemented, all requests for work experience are asked to complete the details below. This information will be separate for monitoring purposes only and is not used in the placement of students.

Gender*	Female Male
Marital Status*
Single Married Widowed Divorced
Ethnic Origin*
White	Mixed
British Irish Any other White background	White and Black Caribbean White and Black African White and Asian Any other mixed background
Asian or British	Black or British
Indian Pakistani Bangladeshi Any other Asian background	Caribbean African Any other background
Other Ethnic Groups
Chinese Any other ethnic background

Please Enter the code below into the box:

Code:
Box:*

DECLARATION

I understand that the volunteer placement if offered will be subject to information given on this form being correct. If it is discovered at a later date that incorrect information has been given, this may result in dismissal or withdrawal of any placement or offer of a placement within the work experience department.

I also understand that the placement will be subject to a satisfactory medical questionnaire and confirm that, to the best of my knowledge, there are no medical reasons, which would prevent me from undertaking work experience.

I also give permission for all the information provided on the form, including that which is considered sensitive under the Data Protection Act 1998, to be used solely for the purpose of recruitment and selection and equal opportunity monitoring and to maintain a record if you are offered a placement in the work experience.

Click here to agree to the above declaration*