Work Experience Application Form
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61. Work Experience Application Form*: Applicant’s Details
Pg 1 of 6
* Applicants seeking work shadowing opportunities should also complete this form.
All information will be treated in the strictest confidence. The information you provide will support your
application & help Dudley and Walsall Mental Health Partnership Trust find you a placement.
Read & complete all sections in full, please print your answers clearly and legibly.
Introduction
Dudley and Walsall Mental Health Partnership NHS Trust is committed to providing work experience placements
wherever possible, however quality of care and patient confidentiality are paramount at all times, so careful
consideration has to be given to where work experience applicants can go, when they can come, what they can
do and how they will act.
Things to be aware of before completing this application
Age restrictions:
standard work experience placements are available for 14 to 18 year olds.
o
Between the ages of 14 and 16 we only offer non-clinical work experience placements in office
environment based environments, these will be at either Bushey Fields Hospital, Clee Ward or at
Trafalgar House; both sites are in the Dudley borough.
o
Between the ages of 16 and 18 we may be able to offer a limited range of fully supervised work
.
experience placements in clinical areas
Other:
A llow plenty of time in advance of any placement for all the arrangements to be made and the
paperwork to be completed – generally 3 months minimum. Be prepared to be flexible about periods of the year
when you can do work experience, as a student you should have a mature outlook and be willing to make the
most of the opportunity.
DATE of Application DD/MM/YY
Please tick or insert ‘y’ for ‘yes’ as appropriate to the question below.
14-18 and seeking Work Experience?
Over 18 seeking up to 5 days work shadowing?
Applicant’s Personal Details
Title
Forename
Surname
Date of Birth dd/mm/yy
Home No.
Mobile
Email address
Home Address, including
post code
Next of kin
Relationship to you
Home No.
Mobile number
Educational Details
(*work shadowing applicants should include most recent educational or work contact details as appropriate)
School/College
Email
Tel.
Address
Reference Details
(*work shadowing applicants should include educational or work reference contact details as appropriate)
In order to make an offer for a work experience we must first obtain a satisfactory educational reference from
your school; please provide details of a teacher, or careers advisor etc. who can provide this:
Title
Forename
Surname
Position
Tel.
Email
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