Work Placement Application 2

Full name *

Address *

Telephone/email *

Emergency contact *

Qualifications *

Registered Training organisation: *

Required placement hours *

Preferred start date *

Availability *

Monday TuesdayWednesdayThursdayFridaySaturdaySunday

Own transport

Resume *

You must have a current DCSI (Department of Communities and Social Inclusion) Child Related clearance. If so, what is the date of clearance? Please provide details, it must be issued within the last two and a half years. *

It is mandatory to have a current Provide First Aid Certification - HLTAID003 - do you have one currently? If so what is the date of issue? If not are you prepared to obtain one prior to starting at your own cost? *

Manual handling certification is mandatory do you have a current one? If so what is the date of issue? *

Do you have a current Child Safe Environment certificate? If you do, please state date of issue, if not, you can only be placed at an adult service *

Name and address of service to be placed at: *

Name of Team Leader/contact phone number: *

Team Leader sign off date/time: *