Work Experience Scheme Confidential Occupational Health Questionnaire

Please select from the drop down menu the organisation where you will complete your work experience.
Please enter your full address, including your post code
Please use the format: dd-mm-yyyy.
Please enter the location in which you will be working
Please enter the number of hours per week you will be working

Health history

Do you have or have you ever had any of the following health problems?

Please use the format: dd-mm-yyyy. Please ensure you have entered the correct year.
Please tick if you have immunity to any of the following
Please type your full name into the field below
To the parent/guardian: by typing your full name below, you are confirming that you give consent for the person mentioned above to participate in work experience with the Trust.
Please use the format: dd-mm-yyyy.

I have read and accept the terms & conditions.