Work Placement Application (copy)

Application form

Date *

Full name *

Gender *

Address *

Telephone/email *

Emergency contact *

Qualifications *

Registered Training organisation: *

Required placement hours *

Preferred start date *

Availability *

Monday TuesdayWednesdayThursdayFridaySaturdaySunday
AM
PM

Own transport

Resume *

It is mandatory to have a current DCSI (Department of Communities and Social Inclusion Child Related clearance - do you have one? If so, what is the date of clearance, if not are you willing to obtain one at your own cost? *

If no, are you willing to obtain one at your own cost? *

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 *

Office use only

Name and address of service to be placed at: *

Name of Team Leader/contact phone number: *

Team Leader sign off date/time: *