Work placement application

Placement you are applying for:

Date of placement:

Surname/family name:

First name:

Date of birth:

Address including postcode:

Home telephone:

Mobile telephone:

Email Address:

Name, phone number and relationship to next of kin or in case of emergency contact

Are you in education:

Yes

If yes please say where you are studying

GCSEs, A levels or other exams taken or subjects being studied:

Previous work experience, volunteering or paid work (if any):

Please let us know the Setting and the Details of Work carried out

Please explain why you have chosen this placement and what you hope to get from it. Include your hobbies and interests and our plans for the future.

Supporting statement

If you are attending a school/college ask a teacher or advisor to provide some information about your application, this could include what they think you might get from the placement, or future career plans. If you do not attend school or college please a

Why is this placement suitable?

Are there any issues that we need to be aware of?

Teacher or advisor name:

Signature:

Telephone Number:

Signed:

I confirm that the information given on this application is correct. I understand that any false information may result in my application being refused or my placement being cancelled.

Print name:

Guardian Name

Today's Date:

Today's date

Parent/guardian’s signature (if under 18):

Date:

This form should be returned either by post or emailed to: