CONFIDENTIAL

APPLICATION FORM FOR WORK EXPERIENCE/SHADOWING

To be completed by student applying for placement. Return to Work Experience Co-ordinator, Orpington Hospital, Training & Development Centre, Sevenoaks Road BR6 9JU Surname: First names(s):

Address:

Email

Date of Birth:

Contact Number:

Do any relatives work for South London Healthcare NHS Trust Yes No If Yes, please state which department?

Preferred date for placement: Duration will be at managers / Trust discretion

Subject currently studying:

Relevant Qualifications /Studies:

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Why have you chosen to apply for a placement at South London Healthcare NHS Trust?

Are you interested in a particular area/s of work and if so, why is this?

Name of College/University/Workplace:

Address of College/University/Workplace:

Contact Details for above:

Name of College/University Tutor/Supervisor :