Your Application:

• Please complete this application form in full and send to [email protected]

• For applicants under the age of 18, we will require permission from your parent/guardian to process your
application. If you are under 18 and a parent/guardian has not signed the application form we will be unable to
look into your request.

Important Information:
• At least 12 weeks’ notice must be given when applying for work experience – if you are unable to provide
your application within this timeframe we may not be able to facilitate your placement for your chosen date(s)
• Due to the number of applications we receive, we are only able to arrange one placement per calendar year to
allow other students to undertake placements
• In addition to the above point, we have restrictions on the amount of placements we can offer. Therefore we
advise all applicants to apply as soon as possible to avoid disappointment (placements are allocated on a first
come basis)
• We predominantly facilitate work experience placements for 5 full days (Monday’s to Friday’s) Weekends are
not available for work experience.
• We cannot guarantee a work experience placement at MPFT. We aim to inform students of any changes to
their placement as soon as possible to allow alternative plans to be made. We encourage students to arrange
an alternative placement in case we are unable to facilitate their request.
• The application asks for one preference. If we are unable to arrange a placement in receipt of your request,
the application will be considered unsuccessful
• During busy periods we may find it difficult to give regular updates regarding the status of your request.
Please bear with us during these times
• Please do not assume a placement has been secured once you submit an application. This must be
confirmed to you in writing.
Data Protection and Confidentiality:

• We are collecting the information within this form to process your data relating to work experience at MPFT.
(The information requested within this application form is used for the arranging of work experience
placements and reporting purposes. Your information is processed by the workforce development team at
MPFT and is shared with the team hosting a placement and may also be used for monitoring and reporting
purposes.)
• Your data will be processed in line with MPFT privacy notice which can be viewed on our website.
https://www.mpft.nhs.uk/about-us/information-governance
• You have the right to withdraw your consent at any given time by emailing us [email protected] to
prevent any further processing of your data. Any data already processed will be deleted where possible.
• I/Parent or Guardian understand that the information within this form may be used for reporting purposes ☐
• I/Parent or Guardian understand that we may be contacted relating to the work experience and a case study
may be requested (case study is optional to you) ☐

Please use the following table as a guide only. Available placements can change based on the team
capacity.

Min
Placement Opportunity Pathway Location (Town) Duration
Age

Dietetics - Stoke on Trent Allied Health Professionals Stoke on Trent 17 1

Adult Community Physiotherapy Service Allied Health Professionals Newcastle 16 5
Podiatry Allied Health Professionals Newcastle 16 5
Podiatry Allied Health Professionals Stoke on Trent 16 5
Podiatry Allied Health Professionals Stoke on Trent 16 5

Community Occupational Therapy Team Allied Health Professionals Longton 14 2

Broadfield Ward - Neuro Physiotherapy Allied Health Professionals Stoke on Trent 16 5
Integrated Physiotherapy, Orthopaedic and Pain Service Allied Health Professionals Lichfield 16 2
Dietetics - Cannock Allied Health Professionals Cannock 17 1
Dietetics - Stafford Allied Health Professionals Stafford 17 1
Adult Community Physiotherapy Service Allied Health Professionals Moorlands 16 5
Community Intervention Team Allied Health Professionals Tamworth 18 5
Community Intervention Service - Physiotherapy Allied Health Professionals Seisdon 16 5
Community Rehabilitation - AHP Allied Health Professionals Lichfield 15 5
Community Rehabilitation - AHP Allied Health Professionals Lichfield 16 2
IPOPS Seisdon Allied Health Professionals Codsall 16 3
Podiatry Department South Allied Health Professionals Cannock 14 5
Adult Community Physiotherapy Service Allied Health Professionals Stoke on Trent 16 5
Children's Physiotherapy North, Hazel Trees Allied Health Professionals Stoke on Trent 16 2
Community Occupational Therapy Team Allied Health Professionals Stoke on Trent 14 2
Community Occupational Therapy Team Allied Health Professionals Newcastle 14 2
Musculoskeletal Integrated Clinical Assessment and Treatment Service Allied Health Professionals Cannock 16 5
Musculoskeletal Integrated Clinical Assessment and Treatment Service Allied Health Professionals Stafford 16 5
Paediatric Physiotherapy - East Children's Physiotherapy Admin Tamworth 16 5
Research and Innovation - North Hub Clinical Admin Stoke on Trent 14 5
High Intensity Team Clinical Admin Stoke on Trent 18 5
High Intensity Team Clinical Admin Stafford 18 5
Palliative and End of Life Service Clinical Admin Newcastle 18 5
Home First (Social Care) Clinical Admin Stoke on Trent 14 5
Infection Prevention and Control Team Clinical Admin Rugeley 15 5
Infection Prevention and Control Team Clinical Admin Stoke on Trent 15 5
Billbrook House Admin Team Corporate Admin Wolverhampton 14 5
Workforce Development Team Corporate Admin Stafford 14 5
Workforce Information Team Corporate Admin Stafford 14 5
School Age Immunisation Team Corporate Admin Stafford 15 3
BeeU Service (0-25 Young People and Families) Corporate Admin Shrewsbury 16 5
BeeU Service (0-25 Young People and Families) Corporate Admin Telford 16 5
Children's & Families Management Admin Team Corporate Admin Stafford 14 2
Community Dental Services Dental Team Stoke on Trent 14 5
Community Dental Services Dental Team Stafford 14 5
Community Dental Services Dental Team Cannock 14 5
Memory and Dementia Service Shropshire Doctors Telford 14 5
Birch Ward, The Redwoods Centre Doctors Shrewsbury 18 5
Forensic Mental Health - Hatherton Centre Doctors Stafford 18 5
Health Informatics Service (HIS) Health Informatics (HIS) Stafford 18 5
Health Informatics Service (HIS) Health Informatics (HIS) Trentham 18 5
Library and Knowledge Services Health Informatics (HIS) Stafford 16 3
Library and Knowledge Services Health Informatics (HIS) Shrewsbury 16 3
Families Health & Wellbeing Service Health Visiting & School Nursing Tamworth 16 3
Shropshire Dementia and Memory Service Multi Telford 14 5
Shropshire Dementia and Memory Service Multi Shrewsbury 14 5
Shropshire Dementia and Memory Service Multi Bridgnorth 14 5
Shropshire Dementia and Memory Service Multi Ludlow 14 5
Shropshire Dementia and Memory Service Multi Market Drayton 14 5
Shropshire Dementia and Memory Service Multi Oswestry 14 5
Community Rehabilitation - General Multi Lichfield 15 5
Seisdon Community Intervention Service Multi Seisdon 16 5
Home First (Community Support Workers, Nurses, AHP's) Multi Stoke on Trent 16 5
Eating Disorders, Kinver Ward Nursing Stafford 18 1
Eating Disorders, Outpatient’s Nursing Stafford 16 5
Armitage,
Tissue Viability Service Nursing 15 5
Rugeley
Tissue Viability Service Nursing Stoke on Trent 15 5
Community District Nursing Nursing Lichfield 16 5
Our Health 5-19 School Nursing Service Nursing Stoke on Trent 16 5
Community Learning Disabilities Nursing Stafford 16 5
Community Learning Disabilities Nursing Lichfield 16 5
Seisdon District Nursing Teams (Community) Nursing Bellbrook 16 5
Seisdon District Nursing Teams (Community) Nursing Wombourne 16 5
Community District Nursing Nursing Tamworth 16 5
Community Rehabilitation (Nursing) Nursing Lichfield 15 5
Community Mental Health Nursing Telford 15 5
School Age Immunisation Team Nursing Stafford 16 3
Our Health 5-19 School Nursing Service Nursing Stoke on Trent 16 5
Our Health 5-19 School Nursing Service Nursing Stoke on Trent 16 5
Ashley House - Forensic Mental Health Nursing Stafford 18 5
District Nursing Nursing Cannock 16 5
Community Children's Nursing Team Nursing Stoke on Trent 15 5
Community Learning Disabilities Nursing Shrewsbury 16 5
Gnosall Health Visiting Team Nursing Gnosall 17 4
Children's Community Nursing Team Nursing Stoke on Trent 16 5
Ashley House - Forensic Mental Health Nursing Stafford 18 5
Ashley House - Forensic Mental Health Nursing Stafford 18 5
Rugeley District Nursing Team Nursing Rugeley 16 5
Baswich Ward - Older Adults Inpatient Mental Health Nursing Stafford 14 5
Dementia and Memory Other - Dementia & Memory Lichfield 14 5
Dementia and Memory Other - Dementia & Memory Cannock 14 5
East Staffs Home First Other - Social Care Burton on Trent 18 5
East Staffs Safeguarding Team Other - Wider Healthcare Team Burton on Trent 16 5
Pharmacy Department Pharmacy Shrewsbury 14 5
Pharmacy Department Pharmacy Stafford 14 5
Diabetic Eye Screening Service Public Health Stafford 16 5
Research and Innovation Research Stafford 14 5
Research and Innovation Research Shrewsbury 14 5
Cannock Respiratory Service Clinical Admin Cannock 15 5
 The Application
1. PERSONAL DETAILS*

Please complete the full application to the best of your ability. Information will be treated in the
strictest of confidence.

Title: Miss Surname: Grewal Forename: Amberjit

2 Swale Grove
Home Address Willenhall
(include post WV13 2SG
code)

Date of Birth: 25/11/2006 Female

DD/MM/YYYY
Gender: Age: 17

Email: [email protected] Contact No: 07413167013

Parent
/Guardian as Jaswinder Kaur
Contact No: 07950235100
emergency (Mother)
contact
School/College
Queen Mary’s Grammar School Contact No: 01922720696
/University:

Where did you hear about us? I saw this opportunity via research
______________________________

2. PLACEMENT DETAILS*

In order to ensure sufficient time is available for your placement to be arranged please ensure you
give 12 weeks’ notice.

Placement Opportunity
Please tell us below which area you are interested in for work experience.
Team Name: Dental team (Community dental services)
Date From: 01/04/2024 Date To: 05/04/2024

Pathway/Area: Dental team

Town/Location: Any from Stafford, Cannock or Stoke on Trent

is fine
3. SUPPORTING INFORMATION*

Why would you like to undertake a placement at MPFT?

In school, I study Biology, Chemistry and Geography and currently I am really enjoying all three
subjects; I am also a member of the Change Your Mind project where you go to Primary schools
and do presentations on important topics that are beneficial for students in Year 5-6. Recently, I
have also been chosen to become a Peer Mentor for the younger years at my school; during these
sessions I’ll have the chance to help students with any social, emotional and academic queries or
worries they may have.
I think that being an active citizen in your local community is really important. Therefore, I make
sure to participate in as much volunteering as I can; during my DofE award, I volunteered at my
local Gurdwara for one year. During this year, I helped with administrative work in reception but I
also had the chance to help teach some younger classes Punjabi; this was really interesting for me
as I love working with children and this is why I want to go into Paediatric dentistry myself.
Teaching the younger children meant I had a chance to develop my communication and teaching
skills but also help children to navigate through their emotions when any issues in class occurred.
I think that having the ability to work with different people and be an empathetic individual are
some really important qualities that you must have when becoming a successful healthcare
provider. Currently, I still like to help out with langar Seva on Sundays which is when you help to
serve the food and I also help with tasks such as washing up and cleaning when I can.
Recently, I’ve started to volunteer with my local GirlsGuiding Brownies Unit and again I’ve really
been enjoying this as I get to work with children of different age groups as they work towards
achieving different badges by completing several activities and expeditions. I like having the
chance to do what I love whilst also having a chance to give back to my local community.
In my spare time, I love to take part in as many sports as I can. At my old school, I was apart of the
netball team and going to netball competitions gave me so many great memories. Aside from this,
I enjoy swimming and playing tennis with my family but recently I have taken up another sport.
About two years ago, I started karate training at my local dojo and I have really enjoyed being able
to build my self confidence and staying active whilst working towards the different belts. Initially,
I started karate as apart of my DofE award but now I have found a sport that I love; being able to
gain new skills and compete at events is something I’ve really enjoyed. At the moment, I am a
brown belt and I’m hoping that in a few months time I will be able to grade for my first black belt
which is something I’m really looking forward to.
I would really like the opportunity to improve the skills that I already work on to become a good
healthcare provider and I feel that being able to take part in this work experience placement would
really help me to achieve that. Gaining experience in a field you’re interested in is crucial to make
sure that you’re making an informed decision and not just making assumptions as to how it would
be, therefore, I feel that this placement would be very beneficial. I would like to gain an accurate
insight into the different areas within dentistry in order to deepen my knowledge of the profession.
I would like to see how dentists are constantly assessing their performance and striving to improve
as I like the idea of lifelong learning and constant reflection. I would like to learn about cosmetic
dentistry as well as paediatric dentistry as I feel like engaging with the cosmetic aspect of
healthcare is something other specialities can’t match.
4. INDIVIDUAL NEEDS*

Do you have any medical conditions or allergies? (Please mark ‘X’ in the box that applies)

Yes ☒
If so, please
No ☐ Eczema and mild asthma
provide details:
 Do you have a disability or additional learning needs? (Please mark ‘X’ in the box that applies)

Yes ☐
If so, please
No ☒
provide details:

5. CONVICTIONS / DISQUALIFICATIONS*

Have you ever been convicted of an offence by civil or criminal court? (Please mark ‘X’ in the
appropriate box)

If yes, please give

Yes ☐
details:
No ☒

6. EQUALITY AND DIVERSITY MONITORING*

Please mark ‘X’

White British ☐ Mixed – White and Afro Caribbean ☐

White – Irish ☐ Mixed – White and Black African ☐

White – Any Other Background ☐ Mixed – White and Asian ☐

Asian or Asian British – Indian ☒ Mixed – Any Other Background ☐

Asian or Asian British – Pakistani ☐ Black or Black British – Caribbean ☐

Asian or Asian British – Bangladeshi ☐ Black or Black British – African ☐

Asian or Asian British – Any Other ☐ Black or Black British – Any Other ☐

Chinese ☐ Other Ethnic Group ☐

I do not wish to disclose my ethnic group ☐

Please read and sign the following. For applicants under the age of 18 parental/guardian signature is
required*

* I/the applicant is not suffering from any medical condition, which might create a hazard to the individual on
work experience or to those working with them ☒

* I/the applicant give permission for the data included in this application form to be used in accordance to
the Information Governance Policy found on our website here Midlands Partnership University NHS
Foundation Trust (mpft.nhs.uk) ☒

By signing this form, you are agreeing to the Terms and Conditions detailed on our website here Work
Experience Page - MPFT Website
Applicants over the age of 18: Please sign below:*

I would like to be contacted in the future relating to other areas of widening participation such as
volunteering, work experience, virtual work experience and other further development opportunities
Yes ☒ No ☐

I consent to being photographed/filmed during work experience which may be used on our MPFT website,
Intranet and social media pages.
Yes ☒ No☐

Name: Amberjit Grewal Date: 26/12/2023

Applicants under the age of 18 – Parental/guardian signature required:*

I would like the student named to be contacted in the future relating to other areas of widening participation
such as volunteering, work experience, virtual work experience and other further development opportunities
Yes ☒ No ☐

I consent to the student named to be photographed/filmed during work experience which may be used on
the MPFT website, Intranet and social media pages.
Yes ☒ No☐

Name: Jaswinder Kaur

Date: 26/12/2023 Relationship: Mother

Please return your completed application form to [email protected]

Workforce Development Team

Trust Headquarters | Corporation Street | Stafford | ST16 3SR