WORK PLACEMENT APPLICATION FORM
School and College Applicants	

Your details Personal Details
Name:		
Date of birth:		
Home Address including postcode:	

Home /Mobile telephone number:		
Email address:		
Name, phone number and relationship to next of kin or in case of emergency contact:		
Address and postcode of school:	
	
Request work placement dates:
(between 1-8 weeks, dependent on service requirement)	From:	To:	

Work Placement Information

Which area of the Council are you applying to complete your work placement in?	

What is your understanding of the tasks you will be expected to perform as part of your work placement?	

	
How will these help towards your future career goals?	

	

School Information
Please give this form to your teacher/tutor or work placement coordinator to complete and sign before sending

Teacher/tutor or coordinator name:
		
School/college Name:

Telephone number:		
Email address:
		
Risks Assessments/Health & Safety Checks

As an employer the council is responsible for the health and safety of the students during their placement, as such the council also has generic insurance which coves people on work placements.

Are there any additional H&S requirements?
If yes, please state:

	
Please state why this placement is suitable for the student?

	
Please state, briefly, what skills, knowledge, behaviour the student should gain from the placement?

	

Signature:								Date:

FURTHER INFORMATION	
Some health problems can affect your choice of work placement or may require us to put things in place to ensure that your placement is safe and appropriate. Please use the space below to tell us about any health problems you think we should know about.	
Skin allergy (i.e. eczema)		Diabetes

Hearing   		Speech

Defective colour vision		Epilepsy		
Eyesight    		Migraine

Physical Movement		Respiration (i.e. asthma)          

Other details: 

	

I confirm that all of the information given on this form is correct: 	
Your signature: 	Date: 	

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.  If you do not hear from us within 4 weeks of receipt of your application you can assume your request was not successful on this occasion. 

You can also contact the Careers Service, who might give you additional support, on this email: Work.Experience@ckcareers.org.uk  or telephone 01484 225500

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EQUAL OPPORTUNITIES MONITORING Form	
The information you put into this form is confidential - you don’t have to complete it if you don’t want to. It helps us better understand our communities and the people we offer placements to. We want to ensure that we are not accidentally prioritising groups of people above others.

The disability section allows us to recommend to your supervisor any adjustments that need to be put in place to assist you during your placement	
Name: 	Male/Female	
Date of birth: 		

ETHNICITY	
How would you describe your ethnic origin? 	
White	English/Welsh/Scottish/Northern Irish/British	Please tick in this column	
	Irish		
	Other (please state)	
Asian	Asian British		
	Indian		
	Pakistani		
	Bangladeshi		
	Kashmiri		
	Other (please state)	
Black	Black British		
	Caribbean		
	African		
	Other (please state)	
Mixed	White and Black Caribbean		
	White and Black African		
	White and Asian		
	Other (please state)	
Other Ethnic Origin	Chinese		
	Other (please state)	

DISABILITY	
Do you consider yourself to be a disabled person? 	No	Yes	If ‘yes’, what is your disability? 

How would this affect your placement? 		
Do you have any additional support requirements? 	No	Yes	If ‘yes’ what are these requirements? 

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