WORK PLACEMENT APPLICATION FORM
University Applicants	

Please email your completed application form and equal opportunities monitoring form to:- WorkPlacements@kirklees.gov.uk.  Application must be submitted at least 8 weeks prior to placement start date. 

Section 1 & 2 – Applicants to complete and sign
Section 3 – Tutor/Work placement coordinator to complete and sign

You will be notified if a placement is available approximately 4 weeks after receipt of your application.

SECTION 1 - 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:		
Name of University:		
How long would you like this work placement for? (between 1-8 weeks)
Please note this will be dependent on the service requirement	Preferred start date?

Preferred end date?
	
Preferred Location for work placement (circle as appropriate)	North Kirklees
South Kirklees	

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: 

	

SECTION 2 - Work Placement Information

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

	
Which skills will you hope to develop during your placement?

	
Can you explain, briefly, how the placement will meet the requirements of your study programme?	

	
Any other information that will support your placement request?

	

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.  

I confirm that all of the information given on this form is correct: 	
Your signature: 	Date: 	
.
SECTION 3 - University Information
Please give this form to your tutor or work placement coordinator to complete and sign before sending

Tutor or coordinator name:
		
University Address:
		
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 any specific targeted work (eg link to a work placement module) that the student should aim to achieve in this placement?	

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

	

Signature:								Date:

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? (Please put an x in relevant column)	
White	English/Welsh/Scottish/Northern Irish/British		
	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 (PLEASE DELETE AS APPROPRIATE)	
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? 

Thank you for taking the time to complete this form