Work experience application form

Please note: While we do our very best to accommodate work experience requests, submitting an application does not always guarantee a placement with us.

Your application will be reviewed and a member of the team will get back to you as soon as possible.

For full details of the application process, please see our work experience page.

Your personal details

Full name

Date of birth

Home Address

Address Line 1 Address Line 2 City County Postcode

Email address

Contact phone number

Emergency contact

Full name

Home Address

Address Line 1 Address Line 2 City County Postcode

Email address

Contact phone number

Parent/guardian

Under 18 years of age: We require parent/guardian consent to progress with your application. Please provide their contact details.

Same as emergency contact

Full Name

Relationship to applicant

Home Address

Address Line 1 Address Line 2 City County Postcode

Email Address

Contact phone number

Monitoring information

Are you currently employed?

Have you had previous experience of working in the NHS?

Are you currently in full time or part time education?

Are you related to a member of Trust staff?

Are you a member of the Armed Forces?

Do you have a disability?

Please select your gender

Preferred pronouns

Please share your pronouns

Please select your ethnicity

Personal statement

Please outline why you are requesting work experience and what you hope to achieve. Please include your future plans and aspirations. (Maximum 200 words).

(maximum 200 words)

About the placement

Which department or job role are you interested in shadowing?

Preferred placement dates

(Monday to Friday only. Please note we will do our best to accommodate but this is not guaranteed).

Date start

Date end

Preferred start and finish time

(hours must be between 9am and 4.30pm)

Start time

Finish time

Preferred placement duration

(maximum of 2 weeks)

I confirm that the above information is true and correct.

Yes

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Work experience application form