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Work Experience Application
Personal Details
First Name
(required)
This field is required
Last Name
(required)
This field is required
Date of Birth
(required)
This field is required
Phone:
(required)
This field is required
Address Street:
(required)
This field is required
Gender
Male
Female
Rather Not Say
Other
Other:
Address Suburb and postcode
(required)
This field is required
Email
(required)
Please enter your email address
Please enter a valid email address
Education Information
School Name or TAFE name or other
(required)
This field is required
Contact Teacher’s name
(required)
This field is required
What are you studying?
Year 10 only
Year 10 and a VET certificate
Year 11 VCAL only
Year 11 VCAL including a VET certificate
Year 11 VCE and a VET certificate
Year 12 VCAL only
Year 12 VCAL and a VET certificate
Year 12 VCE and a VET certificate
a TAFE certificate course only
other
Other:
Home Details
The First and Last Name of your Emergency contact please (an emergency contact when you are on placement)
(required)
This field is required
Their Relationship to you eg : mum, or dad, or sister, or guardian
(required)
This field is required
Emergency Contact’s daytime phone number
(required)
This field is required
How many languages are spoken at home
1
2
3
more than 3
Which languages are spoken at home?
How well do you speak English?
Perfect
Good
OK
Need Help
If you are doing a VET course write the name of the course
Your Placement
What type of work are you interested in? List in order of what you would like (eg Retail, construction, music)
(required)
This field is required
Is there a particular business you are interested in? (eg Coles at Brimbank Shopping Centre). List in order if more than one
What transport are you able to use to get to your placement?
Family car
Train
Bus
Train and Bus
What suburbs are you willing to travel to? (Please list)
Do you have any condition/s that might limit what you can do on placement?
How long is your placement for?
(required)
Please select a value
-- Please Select --
1 week block (that is Monday to Friday)
2 week block
1 day a week
What date are you expected to start your placement?
(required)
Please select a date
What date are you expected to finish your placement?
If your placement is one day per week, which day are you expected to be on placement?
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
I can choose from a couple of days
Is there any further information you would like to add?
Who is paying the placement fee?
-- Please Select --
I will pay online
School has said it will pay
I will pay in person at YouthNow
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