Work Experience Request Form

To be completed by student

First Name

Surname

Phone Number

Email Address

Age at Time of Placement

Gender

Male
Female
Non-binary

Area of Interest

First Choice

Second Choice

Preferred Dates

First Choice

Second Choice

Have you ever been charged or convicted of an offence under the Exhibited Animals Protection Act 1996 (Clause 31A)?

Do you identify as an individual with a disability?

(Disability includes physical, neurological conditions (such as Asperger’s), speech, learning difficulties (such as dyslexia), mental health (such as anxiety, depression) hearing loss and vision impairment.)

If Yes, please outline below including what assistance you may require during the work experience placement.

Do you have any health issues which may impair your ability to effectively undertake the duties of the voluntary position you have applied for?

If Yes, please outline below including what assistance you may require during the work experience placement.

Do you require assistance completing Council’s online induction modules and/or documentation?

If Yes, please outline below including what assistance you will require.

Carer Name (if applicable)

Phone

Parent/Guardian Signature (if student is under 18 years of age)

Date

Emergency Contact Name

Relationship

Phone

Privacy and Personal Information Protection Act 1998

The personal information provided in this document is protected under the Privacy and Personal Information Protection Act (PPIPA) 1998. Wagga Wagga City Council must not disclose your personal information to any person or body if it is not directly related to the purpose for which the information was collected.

The following section MUST be completed for your request to be considered.

To be completed by your Learning Institution

Learning Institution

Careers Advisor/Contact Person

Postal Address

(If your address can't automatically be found, you can still enter it manually)

Contact Number

Emergency Number

Email Address

A copy of your certificate of currency of public liability insurance MUST be attached (current copy).

Public Liability Insurance

Please note: maximum file size is 10MB

I certify the above student is covered for the duration of their work experience placement with Wagga Wagga City Council under the learning institution’s relevant liability insurance.

If you are a student at a NSW Public School or External VET (EVET) provider it is a requirement of the NSW Department of Education that a Student Placement Record (SPR) is completed.

It is the responsibility of the learning institute and/or applicant to ensure that this is completed prior to attending a work experience placement.

Signature

Date

Other Council Websites

Visit Wagga Wagga Airport

Oasis Aquatic Centre Wagga Library

Wagga Art Gallery Museum of the Riverina

Civic Theatre Have Your Say Wagga