GENERIC WORK PLACEMENT 
APPLICATION FORM 	

Please email your completed application form and equal opportunities monitoring form to:- WorkPlacements@kirklees.gov.uk.  Application must be submitted at least 8 weeks prior to placement start date. 

Personal Details	
Title: (select as appropriate)
	
Dr   Mr   Mrs   Miss   Ms  

Other (Please specify)  ________________________________
	
Full Name:
		
Current address:
(including Postcode)	

Email address:		
Telephone/mobile number: 

Emergency contact:

Name:

Telephone number:	

	Opportunity Details	
How long would you like this work placement for? (between 1-8 weeks) Please note this will be dependent on the services requirement		Preferred start date:

Preferred end date:	
Preferred location for work placement (delete as appropriate)	
North Kirklees	
South Kirklees	

Please email your completed application form and equal opportunities monitoring form to workplacements@kirklees.gov.uk

Your application must be submitted at least 8 weeks before you want your placement to start.  

Please Note
Although we will do our best to support you and will get back to you if we can help, Please do remember we can't guarantee you a placement so do continue to search for a placement elsewhere also.  

Please sign and date to confirm that the information supplied is correct:

Signature__________________________________________Date__________________

Work Placement Information  

What area of the council are you interested in carrying out your work placement in
(Please include a first and 2nd choice)?
	
1.	

2.		
Why do you want a work placement within Kirklees Council?	

	
Considering the choices you have made, what are you aiming to gain from your work placement (eg will it support your future career goals)?	

	
Please detail any skills/qualifications/work experience you have had, that can support your request?	

	
Any additional information (eg support needs):	

	

If you need more space, please attach additional sheets and put an x in this box 

If you are required to attend an informal interview, will you require any support   
Yes   / No 

If yes, please give details:

EQUAL OPPORTUNITIES MONITORING Form	

Please submit this form with your application form
Opportunity Details	
Work Placement applied for:		

Applicant’s Name:

Kirklees Council and Partners are committed to employing a workforce that reflects the community we serve.  Please help us to monitor our progress by completing the details below.  Your information will be treated confidentially.

Are You 	Male     Female  	Date of Birth		

I would describe my ethnic origin as (please select x)

White
	
British               Irish  
	
	Other White background (please specify)
	
Asian or Asian British	
Indian   Pakistani   Bangladeshi   Kashmiri 
British 
	
	Any other Asian background (please specify)
	
Black or Black British	
Caribbean      African        British 
	
	Any other Black background (please specify)

Mixed

	
White and Black Caribbean    White and Black African  

White and  Asian    White and Black British 

	Any other mixed background (please specify)
	
Chinese or Other Ethnic	 
Chinese 
	
	Any other ethnic group

I do not wish to disclose information about my ethnic origin     

Disability

Kirklees Council and its Partners have to ask you if you are disabled as defined under the Disability Discrimination Act (1995).  As a disabled person, under this definition, you have ‘a physical or mental impairment which has a substantial and long term adverse effect on your ability to carryout normal day-to-day activities’.

Do you consider yourself to be disabled under this definition?	Yes       No 

If you have answered No to the question above, do you personally consider yourself to be a disabled person?    Yes       No 

Sexual Orientation

If you wish to, you may disclose information about your sexual orientation below:

Heterosexual/Straight     Gay man          Lesbian/Gay woman       Bisexual 

I do not wish to disclose information about my sexual orientation 

Religion

If you wish to, you may disclose information about your religion below:

Christian     Buddhist       Hindu    Jewish       Muslim   Sikh    No religion 
	
Any other (Please specify)		

I do not wish to disclose information about my religion 	

Guidance for Applicants when completing the Equal Opportunities Monitoring Form

The information you provide will be used to produce statistics for equal opportunity and recruitment monitoring only.

Kirklees Council and its partners recognise their responsibility to remove barriers in recruitment, retention and development processes for potential and existing employees and aim to ensure that people from all sections of the community have fair and transparent opportunities.

If you have an impairment which means you identify difficulties or barriers within the work placement or its implementation, please indicate these in your application form and reasonable adjustments will be considered.

It is recognised that all employees have an individual responsibility in the promotion of equality and diversity.

Privacy Notice
Here at Kirklees Council we take your privacy seriously and will only use your personal information within Kirklees Council to support your work placement application.

However there may be occasions, when we are unable to support your work placement request, and will seek support from other organisations such as the Careers Service who might be able to provide additional help in securing a work placement opportunity for you. 

If you consent to us passing your details on for that purpose please tick to confirm

I agree o

We will hold the information about you securely, and no longer than reasonably necessary.

Further information
If you would like further information about how we manage your data, please see the privacy notice for Kirklees Council at www.kirklees.gov.uk/privacy

Thank you for taking the time to complete this form