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STUDENT PLACEMENT / WORK EXPERIENCE APPLICATION FORM

Title:

Mr Mrs Ms Dr

First Name/s:

Family Name:

Tertiary Institution:

Department:

Program / Discipline:

Current year of training
(1st, 2nd 3rd, 4th):

Institute:

Country of Birth:

D.O.B:

Address:

Postcode:

Phone:

Mobile:

Other Phone:

Email:

Fax:

Do you speak another
language?:

Yes No

Date Requested - FROM:

Date Requested - TO:

Availability To Work

Monday:

From Time / am: To Time / pm:

Tuesday:

From Time / am: To Time / pm:

Wednesday:

From Time / am: To Time / pm:

Thursday:

From Time / am: To Time / pm:

Friday:

From Time / am: To Time / pm:

Preferred work areas for placement (you may choose from examples in the box to the right):

	1st Choice	2nd Choice	3rd Choice
Reception
Aged Care
Family Work
Youth Work
Playgroup/s
Ethnic Community (specify from Arabic, Vietnamese, Pacific Islander)

Please list all recent qualifications and training apart from your current course of study:

Current drivers license:

Yes No

Drivers Licence No:

Access to a comprehensively insurance vehicle:

Yes No

Are you willing to work outside of the Campbelltown area?

Yes No

Referee – please list at least one referee

Name:

Position:

Organisation:

Phone:

Name:

Position:

Organisation:

Phone:

Please list your skills and or work
experience including nature of work and dates of employment:

List of hobbies/interests:

Upon submission of the form, you certify that the information you have provided is true and correct. You understand and agree to the following:

MDSI student and work experience placements are voluntary and unpaid
The placement is made for the period requested only, dates may only be extended by mutual agreement between the student and MDSI
While MDSI makes every effort to provide a suitable Student or Work Experience placement for the dates requested, MDSI provides no guarantee that a placement will be made in every case
MDSI reserves the right to refuse Work Experience applications at any time