Work Experience 

Personal Information

Are you over the age of 16? Required
Home address Required

Placement Request Details

Date(s) placement/work experience required Required
Are you planning to apply for a relevant apprenticeship/ university programme? Required


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.


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.

Are you eligible for or in receipt of free school meals?
Have you ever been living in local authority care for a period of three months or more?
Are you a registered young carer?
Are you in employment?
If not in education, training or employment have you had an extended period of unemployment?
Do your parents have a university degree from the UK or abroad?
Do you have a relative(s) working in this Trust?

Equality Assessment Monitoring

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

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.


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