work experience form

Applicant Details

Name

Address

Date Of Birth

Email Address

Preferred Contact Number

Name of Emergency Contact

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

Full Name, Address & Phone Number of School Placement Coordinator

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?

Have you previously taken a work experience placement with ECCH?

About 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

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

ECCH Work Experience Application Form