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Work Experience Application Form

Student Details
Student Name*
First Last
Date of birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Emergency Contact Details
Name*
First Last
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
High School Details
High School name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Level of study*

Eg. Year 12
Contact name*
First Last
Phone*
Email*
Other information
Proposed start date for work experience period*
DD slash MM slash YYYY
Proposed end date*
DD slash MM slash YYYY
Do you have any medical, physical or special need requirements for your work experience?*
If yes, please specify.
Why would you like to participate in a work experience placement at the Central Highlands Regional Council and what area of council are you interested in?*
What do you hope to gain from your time with council?*
What skills do you feel you possess that would enable you to undertake work experience placement within council?*
Date
DD slash MM slash YYYY

Student Details