Work Experience Placement Agreement Form
Please complete all fields in this form, a copy of your responses will then be emailed to you.

You will need your Employers' Liability Insurance details and details of any Public Liability Insurance and Property and Material Damage Insurance, if applicable, when you are completing this form.

Email address *
Student Name: *
Your answer
Placement Start Date: *
MM
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DD
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YYYY
Placement Finish Date: *
MM
/
DD
/
YYYY
Employer Details
Company Name: *
Your answer
Address: *
Your answer
Postcode: *
Your answer
Telephone: *
Your answer
Main Contact: *
Name of Main Contact for this placement
Your answer
Main Contact Email *
Your answer
Position: *
Your answer
Department: *
Your answer
Placement
Placement Job Title: *
Your answer
Brief Description of Duties: *
Your answer
Who to report to on first day? *
Your answer
Uniform/Dress Expectations: *
Your answer
Working Hours: *
Your answer
Breaks: *
How long? How Many?
Your answer
Wheelchair Access? *
Interview Date:
MM
/
DD
/
YYYY
Health and Safety/Insurance
General Information and Insurance
Total Number of Employees *
Your answer
Placement Supervisor Name: *
Your answer
Employers' Liability Insurance: *
Insurer, Policy Number and Expiry Date. If you don't have these details to hand please enter 'TBC' here in order to continue. You can then update this later.
Your answer
Public Liability Insurance:
Insurer, Policy Number and Expiry Date
Your answer
Property and Material Damage Insurance:
Insurer, Policy Number and Expiry Date
Your answer
Click 'NEXT' to read our Conditions of Placement. Please ensure you click 'SUBMIT' at the bottom of the next page, this will log all details.
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