Workplace Learning Continuing Application

Personal Details

If you completed workplace Learning in year 11, you need to complete this form to notify us of your intentions for year 12. Please note, if you are doing Careers and Employability in year 12, you MUST continue with workplace learning on your Flexi day.

Course Name and Training Location

Please indicate how many hours you need to complete and when you would like to do so. Mrs Carson will be in touch with you to confirm dates.

Date of Birth(Required)

Student School Email(Required)

Parent/Guardian Phone Contact(Required)

Parent/Guardian Email(Required)

Emergency Contact Details

Student Medicare Number(Required)

Please include your Medicare reference number.

Medical Details

This information is necessary to assist the Workplace Learning Coordinator and the Workplace Supervisor in the preparation and planning of the student’s work placement. It is a condition of a student’s participation in the program that all relevant information is included here. Students may be withdrawn from Workplace Learning if information is withheld. The Workplace Learning Coordinator may disclose this information to workplace supervisors.

Please provide details(Required)

In the workplace, you may need assistance with…(Required)

Please provide details. Could it affect your performance or safety in the workplace?(Required)

Student Signature(Required)

I certify that the above details are all true and correct. If accepted into the Workplace Learning program, I agree to abide by the decision of the Workplace Learning Coordinator as to my suitability, at any stage for the program.

Workplace Learning Continuing Application