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University Hospitals of North Midlands NHS Trust
University Hospitals of North Midlands NHS Trust MOBILE
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Section 1
Consent
About you
First Name
*
Surname
*
Address
*
Post Code
*
Email Address
Date of Birth
*
Age At Time of Placement
*
What age will the applicant be at the beginning of the placement?
Contact Telephone Number
*
Name of Emergency Contact
*
Placement Dates Required
*
Please give a range of available dates if possible, of when the placement could start and end.
Have you previously attended a placement at UHNM?
*
Yes
No
Under 18
Name of Parent or Carer
*
Email Address of Parent or Carer
Confirm Parent Or Carer
*
Parent
Carer
Previously Attended Placement at UHNM
Previous Placement Details
*
Please provide the dates and departments you were previously placed in.
Placement details
Which hospital site(s) are you applying for?
*
Please note you can apply for both sites (dependent on requested area).
Royal Stoke
County Hospital
Your preferred placement area
*
Which department or occupation would you prefer to be placed in?
Alternative placement area(s)
If it's not possible to place you in your prefereed area, what would your alternative choices be?
Have you already contacted us?
Please tell us if you have you previously contacted a UHNM department or staff member regarding this placement, other than the Work Experience Team? If you have contacted someone, please tell us who.
Any particular requirements to be taken into consideration?
The Trust is committed to supporting people who may have particular requirements that need to be taken into consideration when undertaking work experience. If you have any additional considerations or requirements, please provide details below and we will make every effort to ensure that your needs are met.
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