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Birmingham Heartlands Hospital

Good Hope Hospital
Solihull Hospital
Solihull Community Clinics

WORK EXPERIENCE APPLICATION FORM
Please complete all sections in black ink using capitals as this form may be photocopied
This form needs to be completed by the applicant and sent at least 2 months prior to the requested placement dates. We will
endeavour to place all suitable applicants, but this is subject to demand and hospital requirements, which are beyond our
control. All students must note that submission of this form does not guarantee a placement.
To work in any medical capacity in a hospital, students MUST be in Year 11 or over at the time of placement in order to be
covered by insurance.
As any experience in a hospital will be valuable, students must always be prepared to be flexible in all cases, both in the
hospital location and the department or ward in which they are placed.

Name: …………………………………………….....................Date of Birth: ……………………….
Home address: …………………………………………………………………………………………….
………………………………………………………………………………………………………………...
Home Telephone No: …………………………… Mobile No: ………………………………………..
Email Address: ........................................................................................................................
Emergency Contact/Relationship: …………………………… Contact No: ……………………….
School/College/University Name & Address: ………………………………………………………...
………………………………………………………………………………………………………………...
Tutor in charge of placement: ………………………………………………....................................
Placement Dates:

Start: ………………………… To: ………………………............................

Which hospital/department/speciality would you like to work in? Please give reasons for your choice.
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
Have you already arranged a placement at one of these hospitals yourself? Yes

No

If yes please give details ………………………………………………………………………………..
Course(s) followed: ………………………………………………………………………………………
………………………………………………………………………………………………………………..
What do you hope to do when you leave school/college/university?
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
Please return to:
Access, Placement & Experience Unit
Room 125, 1st Floor
Education Centre
Solihull Hospital
Lode Lane
Solihull
B91 2JL