Hospice Placement Application Form

Placement Application

St Catherine's Hospice is committed to education as a way to support a high quality of palliative care for patients in all settings. Opportunities are available to work alongside and observe our staff in action. Completion of this form will help us to identify the best way to support your learning.

Working in a hospice can affect those who have been recently bereaved. A recent bereavement (within the past six months) will not rule out a hospice placement/visit but it may be helpful to discuss how your placement/visit is managed. If this applies to you, please let us know.

Where an asterisk is visible, this is a required question *

Title

First name

Last name

Telephone Number

Email Address

Confirm Email Address

Have you had a recent bereavement?

Area of Work

Name of organisation where you are based (please don't use abbreviations)

Name of specialism and/or ward department

Length of placement required

Please specify preferred dates or days for your placement at St Catherine's

Please tell us why you would like a placement at St Catherine's - please tick all that apply

General introduction to St Catherine's Hospice for orientation to new role

Part of training course requirements

Independent continuing professional development or personal development plan objective

To develop specific end of life practical skills

To develop specific end of life communication skills

To develop specific end of life skills in working with bereaved people

Other

Please give more details of your objectives (up to three)

Do you require unsupervised contact with patients? If so you will need to produce your DBS (enhanced) certificate

St Catherine’s Hospice will keep your details safe and secure. We will not sell or share your information.

We’d love to keep you updated about our work and how you are making a difference to the people we support. We would also like to send you information about our fundraising and events and other ways in which you can help us.

I am happy to receive occasional phone calls

Yes, I am happy to receive text messages

Yes, I am happy to receive emails

No, I do not want to receive information in the post

More information on how we use your data can be found in our privacy statement.

I confirm I have read the privacy policy and accept how St Catherine’s will handle my information *

For any further questions, or if you would like to change your preferences on how we contact you, please call Anne Truett, Education Administrator, on 01293 447375.