Work Experience Referral Form

For St Michael's Catholic Grammar School. Fields marked with a star are required.

Who Is Completing This Form?

I am the*

Parent/Guardian

Student

Employer / Work Placement Contact

Your name*

Your email*

Student Information

School

Year group

Placement dates *

Start date *

End date *

Student first name*

Student surname*

Form/tutor group

Work Placement Information

Work placement employer / organisation name*

Main business activity

Work placement contact name*

Position

Email*

Mobile *

Country code

Mobile*

Website

Placement Address

Address*

Postcode*

Will the work experience take place at this address?*

Placement Details

Job title*

Description of activities*

Days of attendance per week*

Hours of attendance*

Dress code*

Employer's Liability & Public Liability Insurance

Does the work placement have Employer's Liability Insurance?*

Does the work placement have valid Public Liability Insurance?*

Are written risk assessments in place covering employees, including young people?*

Employer Declaration

Employer name*

Position*

Email address*

Employer declaration*I can confirm that: the employer agrees to offer the placement to the named student; the information provided is accurate; the working environment is suitable and safe for a young person; appropriate supervision will be provided; and the employer may be contacted regarding future work experience opportunities.

Parent/Guardian Declaration

Guardian name*

Relationship to student*

Email address*

Parent/guardian declaration*I can confirm that the named guardian gives permission for the named student to undertake this work experience placement.

Your details are shared with St Michael's Catholic Grammar School and Sirrond to arrange the placement, and deleted 12 months after submission.