| Central Coast Council

Section 1: Personal Details

1. Full name:

2. Address:

3. Contact number:

4. Email address:

5. Date of birth:

Section 2: Emergency Contact Details

6. Name:

7. Relationship to applicant:

8. Address:

9. Contact number:

Section 3: Educational Institution/Referral Agency Details

10. Does your institution/agency cover public liability and indemnity insurance? (Please note work experience applications will only be accepted if applicant is covered by insurance):

Yes

11. Please upload proof of insurance coverage (e.g., certificate of currency). *this is a mandatory field:

One file only.
5 MB limit.
Allowed types: jpg, jpeg, png, pdf, doc, docx.

12. Contact person name:

13. Contact person title/position:

14. Contact person phone number:

15. Contact person email:

Section 4: Work Experience Details

16. Please select the type of work experience/placement that applies to you:

17. Please select which area you wish to complete your work experience:

18. If you selected work experience in a child-related area in Q17, you require a valid Working with Children Check. Please enter your Working with Children Check number:

19. What is the required duration for your work experience (e.g., 1 week, 3 weeks, 1 day per week):

20. Please enter your preferred work experience start date (Please note applications should be submitted at least 6 weeks prior to preferred start date):

21. Please enter any additional comments in relation to work experience dates:

22. Please list what you expect to learn from the work experience/placement that will support your course learning:

Section 5: Student Declaration

23. I will inform my Council supervisor and education institute/referral agency as soon as possible if I am unable to attend the workplace and will inform of injury, accident, incident or near miss that may occur:

I agree

24. I will perform my duties during the placement to the best of my ability; support Work, Health and Safety and professional behaviour in the workplace and comply with all reasonable directions of the Council and its employees:

I agree

25. If I have access during the placement to information which is private and confidential, I will not convey to any person outside the Council’s workplace knowledge or information of this kind:

I agree

26. I understand that I may be required to complete the following pre-placement checks: pre-employment medical/health questionnaire or working with children check:

I agree

27. I understand that I may be required to provide proof of vaccination status depending on the area of work placement/experience I am undertaking (e.g., Tetanus, Boostrix, MMR):

I agree

28. I acknowledge that work placement is voluntary and that I am not entitled to any form of remuneration from Central Coast Council:

I agree

29. Please comment any questions you have regarding completing work experience/placement with us:

30. (High school students only) Please upload a copy of your Student Placement Record. Upload evidence of any qualifications, licenses or tickets relevant for the work experience you are applying (e.g., General Construction White Card for construction related work experience):
One file only.
5 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

31. Please upload evidence of any qualifications, licenses or tickets relevant for the work experience you are applying (e.g., General Construction White Card for construction related work experience):
One file only.
5 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

32. I declare that all information entered in this form is true and accurate. (further permission from Parent or Caregiver will be sought by those under 18)

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