WORK EXPERIENCE

FORM TO BE COMPLETED BY STUDENT & EMPLOYER FOR ‘OWN FIND’ WORK EXPERIENCE
PLACEMENTS
(Student to complete and return to Mr.P.D.Hewitt, Additional Support Coordinator or Mrs K Darroch Howell WEX Administrator)
Please inform your employer that Work Experience is UNPAID)

Student Name: Male/female (please circle)

Tutor
Date of Birth:
Group:
School: Welling School

Date of Placement: 1st Week 6th – 10th December 2010 (inclusive)

2nd Week 13th – 17th December 2010 (inclusive)

Home Address:

Home Telephone No:

Emergency Contact Name
& Telephone No.

Do you have any issues

Yes/No (please circle)
the employer should be
(please complete form HD1 attached)
made aware of?

Relative/Family friend/Neither
Is the company contact a:
(please circle)
Parent/Carer agreeing to this placement Signature of Parent/Carer:
Print Name:

Date of Signature: Signature of

Student:

************EMPLOYER SECTION************

Name of Company:

Type of Business:

Address of Company:

Address of Placement
if different:

Company Telephone
No.
Company email
address:
Brief description of
student tasks

Name and position of

Company contact:

EMPLOYERS LIABILITY INSURANCE (ELI)

Only those with Employer Liability Insurance can be included in Bexley’s Work Experience Programme
Insurance Company:

(ELI) Policy No: Expiry Date:

 FORM HD1

Student Details

Name:

Date of Birth:

Address:

Emergency Contact: Name: Tel:

Home
Name: Tel:
Schoo
l
Please Note: Details:
Any medical conditions
or disability?

Medicine student Details:

takes?

Please note that it is important for the Health and Safety of the students to disclose any issues
that may be relevant.

Behaviour/Learning If yes, please give details.

Difficulties

Yes No

Any other issues Please give details.

Parent/Carer Signature ………………………………………Date………………………….

Print Name ……………………………………………………….

PLEASE SEND THIS FORM BACK TO SCHOOL