WORK EXPERIENCE PLACEMENT - PERSONAL DETAILS FORM
Please complete this form and return to Gillian Carr – gcarr@evelina.southwark.sch.uk
1. Name:
2. Home Address:
2. Contact number/s & e-mail address:
4. Name and address and named contact of school/college/university:
5. Next of kin and their relationship to you:
6. What are your available dates for work experience?
from
to
number of
days/weeks
Please be specific about which days or part days you would prefer:
7. What are you hoping to get out of the placement?
WORK EXPERIENCE PLACEMENT
Student, Parent and Teacher Agreement
1. The Trust places considerable importance on the need for attention to Health and Safety at work. You
have the responsibility to acquaint yourself with the safety rules of the work place, to follow these rules
and make use of facilities and equipment provided for your safety. It is essential that all accidents,
however minor, are reported.
2. The Trust will also expect you to observe other rules and regulations governing the workplace which are
drawn to your attention. Please note that there is a No Smoking Policy covering the whole working
environment and that there are security arrangements applicable to most locations.
3. The Trust fully supports equal opportunities in employment and opposes all forms of unlawful or unfair
discrimination on the grounds of race, ethnic origins, gender, disability, age, religion or sexuality.
4. There will normally be no payment for meals or travelling expenses.
5. Safeguarding children is at the heart of what we do. You must familiarise yourself with the procedures
when you begin your placement and report any concerns accordingly.
I have read and understood the above requirements.
Signed (student):________________________________________ Date:_____________________
If you are under 18yrs of age please obtain the following signatures:
A. Parent/Guardian
I have read the work experience/observation information and understood the requirements. I will ensure the
student carries out these obligations and confirm that he/she is not suffering from any complaint, which might
create a hazard to him/herself or to those working with him/her. I give permission for my son/daughter to
attend the placement and observe during his/her visit to the Evelina Hospital School.
Signature:_______________________________________________ Date: ___________________
B. School Careers Advisor
I have read the work experience/observation information and give permission for this student to attend the
placement and observe during his/her time at Evelina Hospital School. I also confirm that he/she is currently
studying at ________________________________________________________
Signature: _______________________________________________
Date: ______________________
(To be completed by person undertaking the placement)
Equal Opportunities Monitoring Form
Equal Opportunities at Evelina Hospital School
Evelina Hospital School is committed to ensuring that no job applicant, employee or
trainee receives less favourable treatment than others on the grounds of gender, sexual
orientation, marital status, responsibility for dependents, disability, race, national origin,
age, religion, political or trade union affiliations, HIV status or socio-economic
background. To help us to ensure that it’s policy is being carried out, would you please
complete all parts of this form. The information will be held confidentially and may be
used solely for monitoring purposes.
I describe my ethnic origin as: (please tick the appropriate box)
(Ethnic origin does not mean nationality, but normally refers to the people or culture with
which a person's immediate family identify)
 WHITE: British
 WHITE: Irish
 WHITE: Any other white background
 ASIAN OR ASIAN BRITISH: Indian
 ASIAN OR ASIAN BRITISH: Pakistani
 ASIAN OR ASIAN BRITISH: Bangladeshi
 ASIAN OR ASIAN BRITISH: Any other Asian background
 BLACK OR BLACK BRITISH: Caribbean
 BLACK OR BLACK BRITISH: African
 BLACK OR BLACK BRITISH: Any other Black background
 MIXED: White & Black Caribbean
 MIXED: White & Black African
 MIXED: White & Asian
 MIXED: Any other mixed background
 OTHER ETHNIC GROUP: Chinese
 OTHER ETHNIC GROUP: Any other ethnic group
 I DO NOT WISH TO DISCLOSE MY ETHNIC ORIGIN
Gender:
Male
Female
Do you consider yourself to have a disability?
No
Yes
If yes, please give details:
Date of Birth …………………..