Work Experience Application Form

Work Experience Application

Student Details

Student Name*

First Last

Date of birth*

Phone*

Email*

Level of study*

Township for placement*

Emerald

Blackwater

Capella

Springsure

Other (please specify)

Please enter desired location

Emergency Contact Details

Name*

First Last

Relationship*

Phone*

Email*

School or Educational Institution Details

School or Educational Institution name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School work experience coordinator name*

First Last

Phone*

Email*

Other information

Proposed start date for work experience period*

Proposed end date*

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?*

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?*

Disclaimer*

Central Highlands Regional Council (council) is collecting your personal information so that it may contact you for work experience opportunities and complete all relevant documentation as part of this process. To help us gain a better understanding of applicants applying for work experience with council, we also record data for statistical purposes. The information you provide to us will only be accessed by authorised council employees and may be provided to other authorised parties as required by law or as needed as part of our process. For example, your information may be disclosed to the following parties: your parent/guardian, your work experience coordinator and your council work experience placement supervisor. It will not be given to any other persons or agency unless you have given us permission or as required by law. If you do not provide the personal information requested, this may limit the assistance council can provide. Do you agree to the disclaimer listed?

Yes I agree to council collecting my personal information for the purposes described in the disclaimer.

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