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GSTT Medical Work Experience
This form is for Medical Work Experience with a confirmed supervisor only
Please email medicalworkexperience@gstt.nhs.uk if you have any queries
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* Indicates required question
First Name
*
Your answer
Surname
*
Your answer
Please can you confirm you are 16 years of age or older?
*
Yes
No
Gender
*
Your answer
Address
*
Your answer
Borough
*
Your answer
Postcode
*
Your answer
Telephone
*
Your answer
Email Address
*
Your answer
Name, Phone Number and Relationship of Next of Kin or in case of emergency
*
Your answer
Please indicate the type of school you attend
*
Fee-paying
Non-fee paying
Are you currently in education?
*
Option 1
No
Name of school and borough
*
Your answer
In no more than 200 words, please tell us why you have applied for work experience at Guys and St Thomas'
*
Your answer
Describe what you would like to learn and what skills you would like to develop during your placement - include hobbies, interests and your plans for the future
*
Your answer
Name of Supervisor (must be a clinician in the hospital)
*
Your answer
Supervisor Department
*
Your answer
Name of Service Manager in the Department
*
Your answer
Start Date agreed with supervisor
*
MM
/
DD
/
YYYY
End Date agreed with supervisor
*
MM
/
DD
/
YYYY
Please confirm the supervisor has agreed this placement
*
Yes
No
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