Work Placement Form (Block Week) Form
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1* =
compulsory
fields
Work Placement Form (Block week)
Section 1 – To be completed by the student
*Student Name ________________________________________________ Form _____________________
Section 2 – To be completed by the Student
*Name of organisation (CAPITALS)
_______________________________________________________________
Business type (CAPITALS) _____________________________________________________________________
*Address 1 (CAPITALS)
________________________________________________________________________
*Address 2 (CAPITALS)
________________________________________________________________________
*Town / City
________________________________________________________________________________
*Postcode _______________________________________________________________________________
*Company contact telephone ________________________________________________________________
Contact Email ……………………………………………………………………………………………………………………………………………………
*Name of supervisor / contact _______________________________________________________________
Dates of placement from ________________to __________________
Special clothing required ________________________________________ Provided Y / N
Duties of student ______________________________________________________________________
Section 3 – To be completed by Employer
As a representative of the above employer, I confirm that the student named has a placement with the
company on the dates specified and that as a company we have EMPLOYERS’ LIABILITY INSURANCE – PLEASE
ANSWER QUESTIONS BELOW.
*1. Has a risk assessment of your company/organisation been carried out for pre-18 year old workers?
Yes / No
*2. Are there any risks identified in this work experience placement?
Yes / No
*If the answer is yes to question 2, please provide additional written information separately
Certificate Number ____________________________________ Expiry Date_______________________
Name of Insurer _________________________________________________________
Signed ________________________________________________________________
Name _________________________________________________________________
Position _______________________________________________________________
Date _______________________________
Section 4 – To be completed by the Parent/Guardian
As parent/guardian of the named student, I confirm that I agree to the placement and I am satisfied that it is a
suitable environment for my son/ daughter to undertake his/her workexperience.
*Name _________________________________________
*Signed _________________________________________
*Date __________________________________________
Section 5 – To be completed by Student
As the student named above I agree to take part in this work experience scheme. I agree to hold in confidence
any information about my employer’s business that I may obtain during this work period. I also agree to
observe all safety and security regulations in accordance with the company policy.
*Name __________________________________________Signed __________________________
For office use only (Mrs Harris)
Resubmission check passed
Compulsory field check passed Yes
Yes / no
No
referred back to student to action
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