Vocational LearnerInformation Form

Allareas of this form must be completed. If there is any missing information, we will be unable to process your application
Personal Details
Mr/Mrs/Miss/Ms/Other: (please select)
/ Male/Female: (please select)
Full Name:
/
DOB:
Address:
/
Post Code:
Email:
/
Mobile:
/
Home:
School/College:
/
School Year:

Emergency Contact Details(please provide details of next of kin in case of an emergency)

Name:
/ Relationship
Address
/
Post Code:

Mobile:

/

Home:

/

Work:

Date of Work Experience/Placement(placement is a min of 5 and max of 10 working days;day release is a min of 5 working days and max of 3 months-) Please note that placements are Monday to Friday.

Placement Start Date (date must be provided):

/ Placement End Date(date must be provided):

If you have already arranged your own placement at Sheffield Teaching Hospitals, please complete this section

Placement area:
Name of sponsor:
Tel of sponsor:

Additional Information – Essential

Please tell us why you wish to carry out your work experience at Sheffield Teaching Hospitals (STH).The following 3 areas must be included:

(1) Briefly - why you want to do your placement at STH and what you want to get out of your visit:
(2) Which career you are considering:
(3) Which work area/department you would like to carry out your placement:
If you attendcollege, please complete this section
Course:Day released for placement:
Tutor Name :Tutor Tel:

(To be completed by all applicants)

Equal Opportunities Information

Do you consider yourself to have a disability? YES /NO If YES, mark below

Visual Impairment / Hearing Impairment / Epilepsy / Diabetes
Mobility Difficulty / Other Physical Difficulty / Mental Ill Health / Asthma
Multiple Disabilities / Profound/Complex Difficulties / Other
Emotional/Behavioural Difficulties / Temporary Disability after illness or accident

Do you consider yourself to have a learning difficulty? YES/ NO If YES, mark below

Moderate learning difficulty / Severe learning difficulty / Multiple learning difficulties
Other specific difficulty / Other difficulty (e.g. dyslexia) please state..………………………………………..

How would you describe your ethnic origin?

Asian or Asian British – Any other Asian BackgroundMixed – White and Asian

Asian or Asian British – BangladeshiMixed – Any other Background

Asian or Asian British– IndianMixed – White and Asian

Asian or Asian British– PakistaniOther Ethnic Group – Any other Ethnic Group

Black or Black British – AfricanOther Ethnic Group - Chinese

Black or Black British – Any other black backgroundWhite – any other White Background

Black or Black British – CaribbeanWhite British

BritishWhite Irish

Mixed – Any other Background

Please return this form to:

Abby Nicholson

Young Person’s Work Experience Co-ordinator

Health and Social Care Academy

Sheffield City College

Room T318

Granville Road

Sheffield

S2 2RL

Email:

Page 1 of 2