<p> PRIVATE PLACEMENT WORK EXPERIENCE REQUEST FORM TO BE COMPLETED IN BLOCK CAPITALS AND RETURNED TO SCHOOL</p><p>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</p><p>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: ...... </p><p>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.)</p><p>AUTHORISED BY: ……………………………………………………………. CONTACT POSITION: …………………………………………………. PRINT NAME: …………………………………………………………………. DATE: ………………………………………………………………………….</p>