Work Experience Name of Placement Details of Placement (including tasks completed, duration and outcome) Student’s key strengths Student’s areas for development and barriers to learning Student’s interests and hobbies Student’s aspirations for the future Medical Background Current GP Address Name Phone number Please provide brief details where your answer is yes to any question. Student’s NHS number Does the student have any longstanding yes no medical conditions? Is the student currently prescribed yes no medication? Was the student previously on any yes no medication that has since been stopped? Does the student have a history of epilepsy, seizures, fits and/or absences? yes no (If yes, please complete the epilepsy questionnaire following the application) Date of last test Does the student have any hearing yes no dfificulties? --/--/---- Date of last test Does the student have any visual yes no difficulties? --/--/---- Does the student wear glasses? yes no
Work Experience Name of Placement Details of Placement (including tasks completed, duration and outcome) Student’s key strengths Student’s areas for development and barriers to learning Student’s interests and hobbies Student’s aspirations for the future Medical Background Current GP Name Address Phone number Please provide brief details where your answer is yes to any question. Student’s NHS number Does the student have any longstanding medical conditions? yes no Is the student currently prescribed medication? yes no Was the student previously on any medication that has since been stopped? yes no Does the student have a history of epilepsy, seizures, fits and/or absences? (If yes, please complete the epilepsy questionnaire following the application) yes no Does the student have any hearing dfificulties? yes no Date of last test --/--/---- Does the student have any visual difficulties? yes no Date of last test --/--/---- Does the student wear glasses? yes no
RMT-Application-Form-2016.docx