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ECCH Work Experience Application Form

Applicant Details

Name

Full Address & Postcode

Date Of Birth

Gender

Religion

Name of Emergency Contact

Email Address

Preferred Contact Number

This will be the number used for us to contact you in case of a query.

Age

Nationality

Ethnicity

Telephone number of emergency contact

If you are applying for a work experience placement as part of a school careers development week, please complete section below

School/College Name

Name of Careers Advisor or Tutor & Email address

Address & Postcode

Telephone

Year Group

Date and duration of placement being requested

Additional Information

How do you intend to travel to your placement?

Do you have any allergies, disabilities or medical conditions we need to be aware of? (if yes please state below)

(Over 16's Only) Do you have a current DBS check?

Yes No

Have you previously taken a work experience placement with ECCH?

Yes No

Please tell us the dates of when you completed work experience:

Please select one of the options below that best describes you.

Please choose one of the following that applies to you

I am a student I am employed I am unemployed, connected to a job agency or a volunteer

Please state School, College or University

Please state occupational group below

Please specify

Supporting information by applicant

Please select the type of work experience you are applying for

Clinical (Healthcare) Non-clinical (Admin/ Clerical) Year 10 Work Experience

Why have you chosen to apply for work experience at East Coast Community Healthcare CIC

What career or area of healthcare are you interested in and why?

If you are fortunate enough to gain a placement, please explain how you feel this will benefit you in the future

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work experience form

East Coast Community Healthcare CIC

Hamilton House
Battery Green Road
Lowestoft
Suffolk
NR32 1DE

Tel. 01502 445445

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ECCH Work Experience Application Form