We aim to make you work experience of value to you.

To help us arrange your programme, please supply the

following information

Work Experience Application Form

Before you begin:  If completing this form by hand, please use black ink
 Applications may not be considered if full details are not given

Surname: Akinrinola

First name: Abisola

Known as: Abisola (Abi)

Date of birth: 09/10/2008

Address: Flat 10 Cornick House Contact details:

Slippers Place, Bermondsey Please provide at least one telephone number.
Telephone
(home):

Mobile: n/a
Postcode: SE16 2EL Email: Mercydead.444@gmail.com
Role / Profession:
(for work placements)
School / College /
Employer

Address:

Tutor’s / Manager’s Contact details:

Name: Please provide at least one telephone number.
Telephone
(work):

Job Title: Email:

September 2015
September 2015
Why are you It is relevant to my course of study
interested in work
experience / a work I am interested in a career in retail / healthcare, and would like to gain
placement? experience through this programme

Any other reasons (Please specify below)

What are your Aims and Objectives for undertaking work experience / a placement at Princess Alice
Hospice?

Availability
Please indicate your preferred dates for the placement (from one to three weeks’ duration)
Start: End

Weekdays Weekends

Evenings Preferred Hours

Page 3 of 5
W\HR\Work Experience and Placement
September 2015
Work Experience / Placement opportunities
We have many different Work Experience opportunities at the Hospice. Here are some examples of the type of work
that might be available, although this is not an exhaustive list. Please tick all areas that interest you.

Within the Retail Shops /

Within the Hospice
Distribution Centre:
Working with patients and families Banking and cash handling

Therapies Sales and Customer Service

Administration Processing donated stock

Fundraising and income generation Warehouse and stock control

Education Department Window dressing and merchandising

Learning Resource Centre Other (please specify below

Other (please specify below)

Preferred shop location

Many roles require a certain amount of physical activity, such as moving and lifting merchandise or
equipment.
Do you have any health issues or disabilities we
should be aware of, or do you require any Yes No
special adjustments to enable you to carry out (Please specify below)
your duties?

The organisation will not discriminate against current or potential work experience or placement students on the
grounds of age, race, religion or belief, marital status or civil partnership, gender, sexual orientation, gender
reassignment, disability, or pregnancy and maternity.

Within the Hospice we have many opportunities to volunteer

Would you be interested in being contacted

regarding volunteering opportunities in the Yes No
future?

If a placement at the Hospice is greater than three weeks a DBS check will need to be completed
before acceptance of the application. The Hospice will undertake this on your behalf. Previous
criminal convictions will not necessarily prevent full consideration of your application.

References
Page 4 of 5
W\HR\Work Experience and Placement
September 2015
Please give the names and contact details of two people who can act as referees, who have known you for some time
(not relatives). One of them should be your school or college tutor, or someone from your referring organization.

Name: Name:

Title: Title:

Address: Address:

Contact Contact
number: number:
Email: Email:

Relationship Relationship
to you: to you:

Emergency contact details

Name:

Contact
number:
Relationship
to you:

Parental Consent (for applicants who are under 18 years old)

I _______________________ the parent/guardian for the above young person, I give them permission to take
part in the Princess Alice Hospice work experience programme

Signature: Date:

Declaration
I declare that, to the best of my knowledge, the information I have given is true and accurate.

During and after volunteering for the Hospice, I will keep confidential all matters relating to: patients of the
Hospice, their families, friends and carers, other members of staff and volunteers and all Hospice business
matters.

I understand that my personal details will be held on computer in accordance with the Princess Alice Hospice
registration under the General Data Protection Regulation. As a volunteer we will contact you with
volunteering updates and information to carry out your role. For full details of how we use and secure your
data please refer to Volunteering Privacy Notice at www.pah.org.uk/privacy.

Signature: Date:

Please return to the relevant Shop Manager or to volunteering@pah.org.uk

Page 5 of 5
W\HR\Work Experience and Placement
September 2015