Workplace Learning Continuing Application

If you have any questions, please see Mrs Beedie, Head of Careers and VET.

Personal Details

Student Name(Required)

First Middle Last

Date of Birth(Required)

Student School Email(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone Contact(Required)

Parent/Guardian Email(Required)

Emergency Contact Details

Emergency Contact 1(Required)

Name

Mobile Number

Emergency Contact 2(Required)

Name

Mobile Number

Doctor Contact Information(Required)

Name

Surgery

Phone

Student Medicare Number(Required)

Please include your Medicare reference number.

Medical Details

This information is necessary to assist the Workplace Learning Coordinator and the Workplace Supervisor in the preparation and planning of the student’s work placement. It is a condition of a student’s participation in the program that all relevant information is included here. Students may be withdrawn from Workplace Learning if information is withheld. The Workplace Learning Coordinator may disclose this information to workplace supervisors.

Do you have special needs, a disability (physical or learning) or a pre-existing medical condition that could affect your performance or safety in a workplace situation?(Required)

Yes

Please provide details(Required)

In the workplace, you may need assistance with…(Required)

Are you on prescribed medication?(Required)

Yes

Please provide details. Could it affect your performance or safety in the workplace?(Required)

Declaration

Student Signature(Required)

I certify that the above details are all true and correct. If accepted into the Workplace Learning program, I agree to abide by the decision of the Workplace Learning Coordinator as to my suitability, at any stage for the program.

Date(Required)

Parent/Guardian Signature(Required)

I certify that the above details are all true and correct. I give permission for my son /daughter to be enrolled in Workplace Learning. I also give permission for their relevant details to be passed on to the Workplace Learning Coordinator and prospective workplace supervisors. I give permission for the school to provide the Workplace Learning Coordinator with a student photo.

Date(Required)