Form to Be Completed in Block Capitals and Returned to School

PRIVATE PLACEMENT WORK EXPERIENCE REQUEST FORM TO BE COMPLETED IN BLOCK CAPITALS AND RETURNED TO SCHOOL

STUDENT INFORMATION STUDENT NAME:……………………………………………………………… TUTOR GROUP: ………… AGE:…………. GENDER: ...... SCHOOL:………………………………………………………………………….. DATES OF PLACEMENT: ……………...……………..………………. COMPANY INFORMATION PROVIDER/COMPANY NAME: ...... PLACEMENT ADDRESS: ………………………………………………………………… .………..………...... TOWN: ………………………………………………………………… ….……………… POSTCODE: ...... ……………………………………………………………………… TELEPHONE: ………………………………………………………………… ………………….. COMPANY EMAIL: ………………………………………………………………… ………………….. COMPANY WEBSITE ………………………………………………………………… ………………….. WORK EXPERIENCE JOB TITLE: ………………………………………………………………… ………………….. WORK EXPERIENCE ACTIVITIES: ………………………………………………………………… ………………….. ………………………………………………………………… ………………….. CONTACT NAME AGREEING TO PLACEMENT: ...... POSITION IN COMPANY: ...... EMAIL: ...... PERSON TO CONTACT (IF DIFFERENT): ...... POSITION: ...... MOBILE NUMBER: ...... EMAIL: ...... WORKING HOURS: …....……am to …………..pm DAYS OF WORK: MON / TUES / WED / THURS / FRI / SAT DRESS CODE: SMART / SMART CASUAL / OTHER: ………………………………. LUNCH ARRANGEMENTS / BREAKS: ………………………………………………………………… …………………… TRAVEL ARRANGEMENTS: STUDENT RESPONSIBILITY: YES/NO PRE PLACEMENT INTERVIEW REQUIRED? YES / NO

INSURANCE DETAILS (Employers Liability insurance and Public liability insurance are legal requirements for Work Experience.) EMPLOYERS LIABILTY: PUBLIC LIABILTY: Insurance Provider: ……………………………………...... ….. Insurance Provider: …………………………………...... ….. Policy Number: …………………………………....…………...... …………… Policy Number: ………………………………....…………...... …………… Expiry Date: ...... Expiry Date: ......

I CONFIRM THE WORK EXPERIENCE PLACEMENT OFFER FOR THE ABOVE DATES: (This section must be completed / authorised by a company manager or supervisor. A workplace Health and Safety assessment will be carried out, in accordance with Hertfordshire County Council guidelines.)

AUTHORISED BY: ……………………………………………………………. CONTACT POSITION: …………………………………………………. PRINT NAME: …………………………………………………………………. DATE: ………………………………………………………………………….