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Placement Request Form

Personal Details

First Name

Surname

Address:
{For correspondence}

Town

County

Postcode

Check here if you would prefer to be contacted by e-mail.

Home telephone

Working in a hospice involves contact with people who are dying and their families, which can especially affect those who have been recently bereaved. If you have recently experienced the death of someone close to you, please let us know. A recent bereavement will not rule out a hospice placement/visit but we may wish to contact you to discuss how your placement/visit is managed.

Place of Work or Name of Organisation

Address

Town or City

County

Postcode

Job title

Profession

Work telephone number

Work extension

Placement Details

Do you hold a current enhanced CRB certificate?

Please specify

Preferred dates for visit

Is this part of a specialty or vocational course? Please specify

Please identify the type of professionals or department you would like to visit

Are you hoping to meet patients or carers?

If you wish to have patient or carer contact, which must be agreed prior to your visit, please bring with you the original document stating that your enhanced criminal record bureau check is satisfactory.

______________________________________________________________________________________________________________

Please specify your key objectives for the visit and how you wish to address or satisfy these:

First objective and how I plan to achieve this:

Second objective and how I plan to achieve this:

Third objective and how I plan to achieve this:

How will this placement benefit your professional practice and/or your organisation?

Further Information

If `Other`, please give details:

Data Protection:

St Catherine’s Hospice keeps any personal information you supply for the purpose for which you have provided it. It is not passed to other organisations, unless this is made explicit when you supply it. However we may from time to time may wish to send you details of our courses and services.

If you do not wish to receive this information please tick here

Providing care and support to people with progressive life-threatening illness and support to their families, friends and carers in Mid Sussex, Crawley, Horsham and East Surrey.

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St Catherine’s Hospice Ltd. A Company Limited by Guarantee
Registered in England no. 1525404. Registered Office: Malthouse Road, Crawley, W Sussex RH10 6BH. Registered Charity No. 281362

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