Work Experience Arrangement Form Education and Training Reform Act 2006 ~ Ministerial Order 382: Work Experience Arrangements (Schools) STUDENT DETAILS. ‘Sumame First Name Bith Date / Sol Name and pares Coal Maun hy ¢ DAVID SiereT Postcode 3715 Telephone __ Jue 3 Teo Work Experience Coordinator (LATA ieslTR ‘Student Year Level _/0 IN CASE OF AN EMERGENCY, THE EMPLOYER SHOULD CONTACT THE STUDENT'S PARENT OR GUARDIAN AND THE WORK EXPERIENCE COORDINATOI Name (Parent/Guardian) Address Postcode Tel. (Home) (Wot). (Mobile) Emergency contact (Name and Tel.) PRIVACY INFORMATION: The Information provided on this form is for the administration of Work Experience Arrangements only and Is not to be used for any other purpose. Health information will be provided If the Student has a medical condition or requires medication ‘that may be relevant to thelr placement. This information must be kept confidential. TEES Employer (tusiness) name, Tel. Business address Postcode “Type of industry Primary acy at workplace, ‘Student's work location aderess Postcode. ‘Workplace cortact person ‘Supervisor ‘Activities the student wil undertake (f insufcient space, aftach separate sheet) ‘Werk Experience nous amp t6 ‘am pon ONerday Tuesday OWerhestay O Thisday OFitay from (commencement date)__/& JO-7]/6 to (completon date) 22/0 7/16 Total number of days_S Rate ofpayment $e day ($5.00 per day minimum) SEN ee aa L [nam of indvdua, or on bel ofthe Employer i Employers an incorporated bod] agree tha: 1. understand occupational heath ar safety lgisiation and standards relevant the conduc of my underiaking and wil comply wth these ans and standard with espect fo the Sticert asthe Student wore my employee. 2 wilideny a hazards elvan ete conduct of my ungeraking and wil esses and contol al lated risks have rot controled a related "aks I wl inform th schoo of his fact po tothe Work Experience Arrangement commencing 34. Thave read and understocd the Deparment of Edveaion ard Early Chidhood Development Work Experience Guidelines for rployers | wil ensure hat reqited plang, icucton supersion and ste systems of wrk ao provced fore Sudan 0 mala safe se heathy Work Experience Arangement tsi ines. Lal eonsder and take rt account the competency, maturty and physical capabities othe Student in elation oa activites he or she wil Undertake. The Student's program facies willbe planned and eared ou wh these considerations mind Lill mrinate a Superisor (er Supervisors) of the Student who wil be resporsble for ensuing that my obigaions as the Student's Employer fre cared out [vil provide apropiae information, raining, Insructon and supervision to the Student in respect of occupational heath and safety and wi provide any equpnent andirething wich requred to compy wih my duty of care toward he Staaere, Tl ensure thal the Work Experionco is undertaken na non-dsctiinalry and haressmert ee erronment. | ill permit access to the worpiace and cartact wih the Student bythe Principal or the Work Eapeience Coordinator at any reasonase time during te Work experince Arergement Il ensure tha the Wok Experience Arangement isnot used as a substitute forthe employment of employees or the engagement of cnraciors and the payment ot appropriae wages or fe for senfces to employees or coitactors i. 10. | wil ensure thatthe maximum number of studots nthe workplace does net exceed one Student for every three employees. 11. fT have sought to engage more than the permitted numberof Work Experience Students conti ta cect sypenon wil be proved fo all Students. 12, Where the Principal has disclosed any necessary heath information in elation tothe Student | contr that wil maintain he confer of that heath ifermation and only alscise this information to anther party treatment is requied fra known modal Conlon on te esos ol & medial emergency. 18, il noty tho Work Experionce Coorinator es soon a is possible tthe Student is absent, injured or becomes lin the course of undertaking the Work Experience 14. wil consult with be Prncpali | consiert necessary to terminate the Arangomont before the spectea tne. 15. wil advise the Pipl Ie Indy to wren ths Arangement relates clos ptetal exoeure othe Student to scheduled carcnogenic Substances andor oer hazardous sbstarces as defined nthe Oesupatona Heat and Safty Regulations 2007 W the Student Isa Child (under 18 years of age): C2 16. | conti tat have obiained a Chi Employment Permit and that any Supervisor has a current Assessment Nolce and provide cetied copes of thee tothe Prncpal. 17. wl adie the Principal immediatly thre i relevant change in crcumstances wth respect o a Supeniso as specified in section 20(2 of ‘he Working With Chilren Act 2005 (Ve) inetutng, he Supensois charged win, conve for found guy a leva efene, bersres {subject to reporting cbigations, an exerded superison order, supension over detention ordr ora revert findings made agent he Supenfsor. 18, nity ho Principal immediatly ita Supenser i isued wih an interim negetve noice ora negative notice within he meaning a secon 3 othe Working with Gren At 2008. |lunderstand and accept the responsibilties set out above. Following the Principal's review of these details, | understand that he or she will determine. ‘whether or not the Student will undertake the Work Experience Arrangement proposed here. ‘Signature PN ome Date 1 /SURES 1 ‘agree to take part in this Work Experience Arrangement and to: i carry out all reasonable and lawful directions of the Employer and perform my work to the best of my ability; comply with all reasonable workplace rules and requirements governing safety and behaviour; attend at the workplace on each day at the agreed time; 1D inform both the Employer and the Work Experience Coordinator as soon as possible if | am unable to attend work; D promptly inform the Employer of any accident, injury or incident that may occur; O dress appropriately for the workplace; a sare that no payment will be made to me if the placement is with a Commonwealth Department or a body established under a Commonwealth O give my consent to donating back payment where the placement is with an organisation engaged wholly or mainly in an educational, charitable or Community welfare service not conducted for profit and where | have determined that the whole of my payment will be donated back to the organisation. ‘Students aged 18 years and over: 1 agree to inform the Employer of any necessary medical information, including details of any known medical condition which may affect me and ‘any medication or treatment which may be relevant. D1 | understand that | am responsible for my transport to and from the workplace. | understand thatthe Principal will determine whether or not | will undertake Work Experience. | acknowledge that prior to commencing the placement under this Arrangement | wil complete the occupational health and safety program required by the Department of Education and Early Childhood Development. ‘Student’ signature, Date / / OREN EGNOS SSE \, consent to my child taking part inthis Work Experience Arrangement and I: agree that he or she will be subject to the direction and control of the Employer and nominated Supervisor(s); understand that all reasonable care for the health and safety of my child will be taken by the Employer and nominated Supervisor(s); expect my child to comply with all reasonable workpiace rules and requirements goverring safety and behaviour; understand that am responsible for my chile's transport to and from the workplace; C1 agree that no payment will be made to my child if the placement is with a Commonwealth Department or a body established under a ‘Commonwealth Act; Cie my consent to my child donating back payment where the placement is with an organisation engaged wholly or mainly in an educational, Chartable or community welfare service not conducted for profit and where my child has determined that the whole of his or her payment will be donated back tothe organisation; 1D understand that | wil be notified as soon as possible inthe event of illness of or accident to my child, but where itis impracticable to communicate with me | authorise the person in charge at the workplace of the empioyer to consent to my child receiving such medical and surgical treatment {including the administration of an anaesthesia) as may be deomed necessary by a legally qualified medical practitioner, and administer such first-aid as is judged to be reasonably necessary; O attach details of any known medical condition which may affect my child, and any medication or treatment which may be relevant; O give my consent tothe release of any necessary health information in relation to my child by the Principal to the Employer, for which the Principal is aware of and may cisclose pursuant to the Health Records Act 2001 (Vic). | understand thatthe Principal will determine whether or not my child will undertake Work Experience, Signature GParentor Guardian Date / / DEES SSNS “The Student is covered for WorkSafe Insurance by the Department of Education and Early Childhood Development (Stat oe by publ lability insurance in accordance with Ministerial Order 382 ~ Work Experience Arrangements, fo the arrangement taken out by the indicated below (Principal o tick the appropriate box) Department of Education and Early Childhood Development Non-Government schoo! O Employer NOTE: PUBLIC LIABILITY INSURANCE Public lability insurance of atleast $10 milion cover per event must be held or taken out, prior to the Student commencing Work Experience under ‘the Arrangement: ‘when an Arrangement is entered into by a Principal of a Government School in respect of a Government Schoo! student, by the Department of Education and Early Childhood Development with the incured being the Student and the Employer. Ji. when an Arrangement is entered into by a Principal of a Non-Government Schoo! in respect of a Non-Government School student ~ ether: ‘2. by that School, with the insured being the School and the Student; or by the Employer, with the insured being the Employer and the Student, if the Principal ofthat School has advised the Employer at Teast four (4) weeks prior to the Student commencing work experience that the School does not have publi iailty insurance as set out above GES f ge ree Principal of_LMLOR Sov PNEY Counce ‘enter into an Arrangement for the above named Student of this school to be engaged for the purpose of Work Experience by the Employer rnamed above in accordance with the provisions of the Education and Training Reform Act 2006 and Ministerial Order 382 — Work Experience ‘Arrangements, and on the basis of the information provided above and the employer's acknowledgements. | confirm that I have informed the Employer as to whether this schoo! holds public lability insurance. | will ensure that the above mentioned student will complete the required ‘occupational health and safety program prior to commencing the placement under this Arrangement. Date ff Principals signature