WORTHING HOSPITAL, WEST SUSSEX
WORK EXPERIENCE
APPLICATION FORM
Before completing this information sheet please be sure that you meet the criteria
for shadowing here at Worthing Hospital. The main criteria is that you are 16+ and
in the lower 6th studying for A or AS level examinations.
Name:
Address:
Home Telephone Number:
Mobile Number:
Email Address:
Date Of Birth:
Age:
Name and Address of School:
Telephone Number:
Contact - Tutor /Careers Officer :
Please list here the subjects that you are currently studying or have studied:
Please list the results of any examinations that you have taken e.g. GCSE’s, AS Levels,
A Levels
July 2013
Any Specialised Interests/Hobbies
Are you intending to enter higher education, or return to full and part time
education? (e.g. go to college or university)
Where are you hoping to study?
What subject/subjects are you hoping to study?
Why do you want to carry out work experience at Worthing Hospital
What attracted you to Worthing Hospital
Please gives dates below that you are available to carry out your work experience
July 2013
We receive numerous requests for work experience placements at Worthing
Hospital and we are limited in the number of placements we are able to offer.
Consequently, we are only able to offer placements to students or persons with a
genuine interest in pursuing a career in medicine.
In order to assist your application, please state below why we should offer you a
placement in preference to another student.
July 2013
Have you undertaken any other work experience?
Do you do any type of voluntary work?
Signed:
Date:
As part of the application process I need a letter from your
school supporting your application and which also confirms that
you are likely to get the required grades to get into medical
school.
Thank you for completing this form
I will be in contact as soon as I can
Please return this form to:
Debbie Kitchener
Undergraduate Administrator
Worthing Health Education Centre
Worthing Hospital
Park Avenue
Worthing
West Sussex BN11 2HR
debbie.kitchener@wsht.nhs.uk
Please allow as much notice as possible as work experience placements get booked
up very quickly and are filled on a “first come first served basis”
July 2013