Expression of Interest Workplace Learning Application Form

1. Personal details
Name Name First Middle Last
Gender

Gender Female Male Prefer not to say Other
Date of birth Date of birth / DD / MM YYYY
Are you of Aboriginal and/or Torres Strait Islander descent?

Are you of Aboriginal and/or Torres Strait Islander descent? Yes No Prefer not to say
Has anyone in your family attended University?

Has anyone in your family attended University? Yes No
Are you an Australian citizen or permanent resident of Australia?

Are you an Australian citizen or permanent resident of Australia? Yes No
Do you require any reasonable adjustments to take part in the workplace learning program? This may include medical conditions or special requirements whilst on placement. e.g: ramp for wheelchair access, vision impaired software...
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Is above address the same as postal address?

Is above address the same as postal address? Yes No
Postal address Postal address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Best contact phone number (no spaces between numbers)
Email
2. School/Training Provider Details
School/Training Provider name
Current year attending (if Training Provider, current course/year)
School Careers Advisor name School Careers Advisor name First Last
School Careers Advisor phone
School Careers Advisor email
I have informed my Careers Advisor I am seeking a work placement

I have informed my Careers Advisor I am seeking a work placement Yes
I am aware that if my work placement request is approved then I will need to liaise with my careers advisor and complete a Student Placement Record

I am aware that if my work placement request is approved then I will need to liaise with my careers advisor and complete a Student Placement Record Yes
I understand I will have to organise my own transport arrangements to and from the campus

I understand I will have to organise my own transport arrangements to and from the campus Yes
3. Work placement request details
Placement type
If other
What field are you interested in? Some examples: Science Medicine and Health, Equity, Wellbeing, Law, Business, Marketing, Engineering and Information Sciences, Social Sciences, Humanities and Arts. https://www.uow.edu.au/index.html.
Why are you interested in completing a placement with this area? Is there any specific interest areas you were hoping to gain experience in? (eg refer to career/study goal)
Maximum of 300 words allowed. Currently Entered: 0 words.
What will you be able to bring to this placement? (eg motivation and interest to learn)
Maximum of 300 words allowed. Currently Entered: 0 words.
Please list up to 3 suitable work placement date options. This can be specific or open ended.
Date option 1
Date option 2
Date option 3
Are you flexible with these dates?

Are you flexible with these dates? Yes No
4. Information & consent
Parent/Caregiver name Parent/Caregiver name First Last
Parent/Caregiver phone
Parent/Caregiver email
The parent/caregiver above is my emergency contact

The parent/caregiver above is my emergency contact Yes No
Please provide your emergency contact person
Emergency contact name Emergency contact name First Last
Emergency contact phone
Emergency contact email
Relationship to yourself
I authorise my school to receive information pertaining to my application, enrolment, and to make enquiries on my behalf

I authorise my school to receive information pertaining to my application, enrolment, and to make enquiries on my behalf Yes No
5. Disclaimer
University of Wollongong may occasionally use photography and digital media for publicity purposes and showcasing the work of the students. I hereby consent for UOW and/or its representatives, agents and related entities to use any photographs or videos of my appearance, for possible inclusion in UOW publications, websites and other publicity material. I understand that the image will remain the property of the University of Wollongong, and will be used for the designated purpose of promoting UOW.

University of Wollongong may occasionally use photography and digital media for publicity purposes and showcasing the work of the students. I hereby consent for UOW and/or its representatives, agents and related entities to use any photographs or videos of my appearance, for possible inclusion in UOW publications, websites and other publicity material. I understand that the image will remain the property of the University of Wollongong, and will be used for the designated purpose of promoting UOW. Yes No
I understand that the submission of this application does not mean placement is guaranteed. Placement is dependent on availability within the units and faculties of the University.

I understand that the submission of this application does not mean placement is guaranteed. Placement is dependent on availability within the units and faculties of the University. Yes
I understand that if work placement is approved a Student Placement Record (SPR) form is required within 7 working days.

I understand that if work placement is approved a Student Placement Record (SPR) form is required within 7 working days. Yes
7. Privacy Policies

Private information received will be kept securely and only shared on a needs based system. Please refer to UOW’s Privacy Policy for further information.

Please refer to NSW Department of Education Privacy Notice:

Privacy notice – for all parties
The information provided by students, parents/carers and employers is obtained for the purpose of coordinating a workplace learning opportunity for the school student. The NSW Department of Education and Training will use the information to meet duty of care and child protection responsibilities and to support the information needs of the student, employer and the parent/carer. The Local Community Partnership might access information related to HSC VET work placements but only with the approval of the Principal. Providing this information is voluntary. However, if you do not provide any of the information requested then the student may not be able to undertake the planned workplace learning. The information you provide will be stored securely and kept for a minimum of two years where there is no further action relating to the placement. The information will only be disclosed for purposes directly related to the purpose for which it is collected. You may correct any personal information by contacting the teacher in charge of the student’s workplace learning program at the student’s school. This may be the careers adviser or the student’s HSC VET teacher or subject teacher.
I have read and understand the Privacy Notice from both UOW and the NSW Department of Education

I have read and understand the Privacy Notice from both UOW and the NSW Department of Education Yes No

Expression of Interest Workplace Learning Application Form

Expression of Interest Workplace Learning Application Form

1. Personal details

2. School/Training Provider Details

3. Work placement request details

4. Information & consent

5. Disclaimer

7. Privacy Policies