OXFORDSHIRE WORK EXPERIENCE SCHEME
WORK EXPERIENCE
STUDENT APPLICATION/OWN PLACEMENT FORM 2011/12
This form should be completed neatly in black ink and signed by you ,your parent/guardian and the employer offering your placement. This form must be completed and returned by the given deadline. School/College Name Work Experience dates JULY 8th - JULY 12th
LANGTREE SCHOOL Work Experience co-ordinator Name
MR I BLOWER
School Tel. No.
Student Name
Date of Birth
Home Address
Home Tel. No.
01491680514
Mobile No. Post Code
Email address
Emergency Contact name
Emergency Tel. No.
Relationship to student PARENT/GUARDIAN- please complete this section Please indicate below any medical condition/s and/or special needs this student has which a placement provider should be aware of in order to carry out a suitable and sufficient risk assessment. Eg: Asthma, allergies, hay fever, colour blindness, epilepsy, diabetes, eczema, phobias, learning difficulties, Failure to notify us of any condition could put a student at risk.
STUDENT AGREEMENT Student Name
School/College
•
I agree to participate in a Work Experience placement.
•
I agree to hold in confidence any information about the Placement Provider’s business that I may obtain during the placement and not to disclose such information to any other person without the Placement Provider’s permission.
•
I agree to observe all health, safety, security and other rules laid down by the Placement Provider and made known to me verbally, in writing, or by displayed instructions.
•
I agree to inform the Placement Provider as soon as possible of any absence from the Work Experience placement.
Student signature
Date
PARENT/GUARDIAN AGREEMENT Parent/Guardian Name •
I agree in principle to the above student undertaking work experience with the employer overleaf.
•
I have provided any relevant medical information as required.
•
I understand that parents/guardians have responsibility for safety whilst the student is travelling to and from the placement.
•
I understand that the placement provider has responsibility to ensure that so far as is reasonably practicable all necessary health and safety measures will be taken during the placement.
•
I understand that the placement provider will have to satisfy to satisfy the OCC Work Experience standard relating to insurance cover, health and safety at work, working conditions and risk assessment
Parent/Guardian signature
Date
PLACEMENT INFORMATION PLEASE COMPLETE ALL FIELDS Name of organisation offering placement Address Contact’s Name
Post Code
Contact’s job title
Telephone No.
Email address
Organisation’s Employers Liability Insurance Policy Number Placement job title and/or description
Organisation’s Employers Liability Insurance expiry date
EMPLOYER AGREEMENT – MUST BE SIGNED BY EMPLOYER • I understand that I will be contacted by OCC Business & Skills team in relation to work experience processes and may be visited by the team for health and safety purposes. I agree to OCC holding information regarding work experience placements on their Work Experience database systems and sharing this information with schools, students and parents. I have read the 'Information for Employers' leaflet and understand I will be notified of student name/s and placement information prior to the placement start date. I understand the student will also contact me prior to starting. I confirm I will have appropriate Employer Liability Insurance to cover work experience students in place for the placement duration (and have notified my brokers if necessary) I am aware of the requirement on employers to complete a suitable and sufficient risk assessment and to provide information to a parent/guardian for a child of compulsory school age in accordance with the Management of Health and Safety at Work Regulations 1999 (as amended). I will undertake to provide induction training, including Health and Safety and emergency arrangements. I will undertake to have due regard for the welfare of the young people in the workplace and understand that it may be necessary to undergo a Criminal Records Bureau Check in line with the ‘Safeguarding of Children in Education’ [DfES Guidance September 2004] I will notify the school in the event of any absence, early termination of placement, injury, or any other difficulties regarding the student, or should an incorrect student appear. Employer signature
Date
Employer Name
Employer job title
Student Signature
Parent/Guardian Signature
STUDENT APPLICATION/OWN PLACEMENT FORM 2011/12
This form should be completed neatly in black ink and signed by you ,your parent/guardian and the employer offering your placement. This form must be completed and returned by the given deadline. School/College Name Work Experience dates JULY 8th - JULY 12th
LANGTREE SCHOOL Work Experience co-ordinator Name
MR I BLOWER
School Tel. No.
Student Name
Date of Birth
Home Address
Home Tel. No.
01491680514
Mobile No. Post Code
Email address
Emergency Contact name
Emergency Tel. No.
Relationship to student PARENT/GUARDIAN- please complete this section Please indicate below any medical condition/s and/or special needs this student has which a placement provider should be aware of in order to carry out a suitable and sufficient risk assessment. Eg: Asthma, allergies, hay fever, colour blindness, epilepsy, diabetes, eczema, phobias, learning difficulties, Failure to notify us of any condition could put a student at risk.
STUDENT AGREEMENT Student Name
School/College
•
I agree to participate in a Work Experience placement.
•
I agree to hold in confidence any information about the Placement Provider’s business that I may obtain during the placement and not to disclose such information to any other person without the Placement Provider’s permission.
•
I agree to observe all health, safety, security and other rules laid down by the Placement Provider and made known to me verbally, in writing, or by displayed instructions.
•
I agree to inform the Placement Provider as soon as possible of any absence from the Work Experience placement.
Student signature
Date
PARENT/GUARDIAN AGREEMENT Parent/Guardian Name •
I agree in principle to the above student undertaking work experience with the employer overleaf.
•
I have provided any relevant medical information as required.
•
I understand that parents/guardians have responsibility for safety whilst the student is travelling to and from the placement.
•
I understand that the placement provider has responsibility to ensure that so far as is reasonably practicable all necessary health and safety measures will be taken during the placement.
•
I understand that the placement provider will have to satisfy to satisfy the OCC Work Experience standard relating to insurance cover, health and safety at work, working conditions and risk assessment
Parent/Guardian signature
Date
PLACEMENT INFORMATION PLEASE COMPLETE ALL FIELDS Name of organisation offering placement Address Contact’s Name
Post Code
Contact’s job title
Telephone No.
Email address
Organisation’s Employers Liability Insurance Policy Number Placement job title and/or description
Organisation’s Employers Liability Insurance expiry date
EMPLOYER AGREEMENT – MUST BE SIGNED BY EMPLOYER • I understand that I will be contacted by OCC Business & Skills team in relation to work experience processes and may be visited by the team for health and safety purposes. I agree to OCC holding information regarding work experience placements on their Work Experience database systems and sharing this information with schools, students and parents. I have read the 'Information for Employers' leaflet and understand I will be notified of student name/s and placement information prior to the placement start date. I understand the student will also contact me prior to starting. I confirm I will have appropriate Employer Liability Insurance to cover work experience students in place for the placement duration (and have notified my brokers if necessary) I am aware of the requirement on employers to complete a suitable and sufficient risk assessment and to provide information to a parent/guardian for a child of compulsory school age in accordance with the Management of Health and Safety at Work Regulations 1999 (as amended). I will undertake to provide induction training, including Health and Safety and emergency arrangements. I will undertake to have due regard for the welfare of the young people in the workplace and understand that it may be necessary to undergo a Criminal Records Bureau Check in line with the ‘Safeguarding of Children in Education’ [DfES Guidance September 2004] I will notify the school in the event of any absence, early termination of placement, injury, or any other difficulties regarding the student, or should an incorrect student appear. Employer signature
Date
Employer Name
Employer job title
Student Signature
Parent/Guardian Signature
