Ark Academy

Bridge Road
Wembley HA9 9JP
Work Experience Placement Form 2019

Students must complete and return this form to Mrs Boyle no later than Friday 3 rd May 2019.

STUDENT INFORMATION
Work Experience:
Monday 2 September – Friday 6th September 2019
nd

Name: Form:
Address Name of
: Placement:
Location of
placement
[including
postcode]:

Student Work Experience Agreement

I agree to take part in the placement as described throughout this form and will adhere to the standards expected of
me while I am the place of work. I will follow the workplace’s health & safety procedures and any training that I am
required to take. I will also report any concerns I have regarding the placement and/or health & safety to a senior
member of staff. I will carry out the tasks required of me during the placement to the best of my abilities.
Signature Date:
:

Parent/Carer/Guardian Agreement
As the parent/carer/guardian of the named student, I consent to them taking part in a work experience placement
with the named employer as described throughout this form. I have advised on any medical conditions, learning
difficulties, or other vulnerabilities the student has that may affect their ability to carry out certain duties and/or
affect their health and safety.
Name Date:
[print]:
Signature
:

A number of useful documents are available on the school website:

www.arkacademy.org/secondary/careers

Documents include the following:

 Safeguarding Young people on Work related Learning including Work Experience

[Department for Children, Schools and families]
 Young people & Work Experience: A Guide to Health and Safety for Employers [Health &
safety Executive]
 EMPLOYER INFORMATION
To be completed by the employer. Please complete clearly and in full.
Only employers with Employer’s Liability Insurance will be used for Work Experience.
Name of Name of Contact:
Company:

Address: Phone Number

[of contact]:
E-Mail address [of
contact]:

Name of Policy Number:

Employers
Liability Expiry date:
Insurance
Company:
Do you have Who are your
public liability premises Health & Safety
YES NO Local Authority
insurance? registered with? Executive

Do you have a
written Health &
safety policy
statement?
Describe the
health & safety
hazards that exist
and the safety
control measures
that are in place
to minimise the
risks
Description of
placement:
Describe the
job[s] that the
student will carry
out. State which
department they
will be working
in.
Working Hours: Lunch/Break
Time:
Specific Job
requirements:

Employer Agreement
Our organisation agrees to provide the named student with a work experience placement. We also agree to provide the student
with the necessary information, instruction and training so they know how to fulfil their role properly and do so safely.
Name Date:
[print]:
Signature
: