CHC50121-LDC Work Placement Booklet 1 V3 09.09.23

Work Placement Booklet 1
Long Day Care

Diploma of Early Childhood Education & Care
(CHC50121)
Student Name:
Student Email Address:
Trainer/Assessor Name:
h&h Accredited Training

98 South Street Granville | 02 9682 0100 | www.hnh.org.au | to 45704
h&h Accredited Training Pty Ltd
Diploma of Early Childhood Education & Care Work Placement Booklet 1
Eligibility
Upon completing specified units in their course, a student is eligible to participate in work placement. The student
is only deemed eligible to participate if they possess the required attributes and skills.
Work Placement Overview
During work placement, the student puts their learned skills and knowledge into practice in an actual workplace.
The student is supervised by a workplace supervisor and will be assessed by an h&h Trainer/Assessor.
During workplace visits, the Assessor will use the Work Placement Booklet, adding the workplace supervisor's
observations, and determining if the student is competent in the workplace.
Trainer Declaration
I __________________________________________ (Trainer/Assessor) verify that the student has demonstrated

the workplace skills and knowledge in accordance with the Diploma of Early Childhood Education & Care.
I further acknowledge that I have visited the student during their 80 hours of practical work at approved
organisation.
Trainer / Assessor Signature: Date / /
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INSTRUCTIONS TO THE ORGANISATION HOSTING OUR h&h STUDENT

We would like to take this opportunity to thank you for supporting our student as they learn valuable skills in the
workplace.
The hosting organisation is required to complete the following sections ONLY.
1. Observation Permission – Third Party Declaration

2. Supervisor feedback (overall feedback on completion of the work placement)
3. Orientation Checklist
4. Attendance record – Supervisor signature section only
Thank you again,

The h&h team
THIRD PARTY DECLARATION (to be completed by the Supervisor/Manager) Tick
I have received a copy of the h&h Memorandum of Understanding (MOU) outlining the student's details
including dates of work placement, prior to commencing.
I understand that the h&h Trainer/Assessor will be required to attend our site a minimum of two visits to
assess the student's skills.
I am aware that the student may be required to access the policies and procedures and other relevant
workplace documentation.
I understand that the student will need to engage with all stakeholders to be able to successfully complete
assessment requirements.
The workplace is required to complete an onsite induction on the student’s first day of placement (orientation
checklist).
Permission granted:
I, _____________________________ (supervisor name) have provided permission to this student, to have

access to relevant documentation and policies and procedures while on work placement at this service or
organisation. It is noted that names will not be used, photos will not be taken, and strict privacy and
confidentiality will be upheld during the hours on site.
Supervisor/Manager Signature: _____________________________ Date: ___/___/____
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SUPERVISOR FEEDBACK (to be completed at the end of work placement)

Please note: This assessment provides a third-party testimonial about the student's performance and skills while
at your service. It also supports the evidence gathered by the trainer about the trainee during their training. Your
contribution to this process is vital for the overall assessment of the student. We appreciate your comments.
Please tick the response that you feel best describes the student's performance in the table below:
Name of workplace Supervisor/Director: Direct contact phone/email:
Checklist Completed Comments
The student went through an orientation/induction on their first □

day
The student understands and follows clear directions efficiently □
The student has a clear understanding of the work role in early □

childhood education and care
The student appears committed to the rights of the children □
The student is communicative when there is a lack of □

understanding with a task
The student demonstrated a clear understanding of manual □
handling and infection control
The student has a caring and supportive attitude with the □
children
The student displays a high level of patience, discretion, and □
professionalism
The student has good general communication skills □
The student provided assistance with daily tasks such as nappy □

changing, storytelling etc
The student showed awareness of safety hazards in the □
workplace
The student demonstrated an ability to work with children who □
required assistance
The student showed a high degree of compassion and support □
for the children
The student was able to work in an environment where there □
were cultural differences, and age differences, with both the
client and co-worker
Supervisor/Manager Signature: _____________________________________________ Date: ___/___/____
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ORIENTATION CHECKLIST (to be completed by Supervisor/Manager)

The student is required to complete this on day one (1) of the work placement with the Supervisor/Manager.
Please tick the components below:
I have:
1. Participated and gathered information on the following:
o Undertaken a tour and physical orientation of the service

o Verified working dates and times with the Supervisor/Manager
2. Located the evacuation and fire safety policy and procedures:
o Extinguishers/fire blanket location

o Exit signs and assembly points location
o I understand my responsibility in the event of an emergency
3. Identified the emergency response procedure:
o In the event of an emergency, I am aware of the emergency phone number/call sign

o I am aware of the procedure for personal threat/duress alarm in the event of an emergency
o I understand my responsibility in the event of a medical emergency
4. Located the infection control policy:
o I understand the procedure for managing a spill (eg. water)

o I am aware of the procedure for disposing of soiled items
o I am aware of the management of waste sharps
5. Located the incident, accident and complaints reporting procedure:
o I have located the incident, accident and complaints reporting procedure and am familiar with these
policies
6. I have located the following items and have familiarised myself with them:
o Nappy change table; cleaning equipment, wet ones, and paper towels
o Cleaning and maintenance products (securely stored)
o Toy room supplies and equipment (matched to the development of the children)
o Drinking water
Student Name: __________________________ Signature: _______________________ Date: __ / __ / __
Supervisor/Manager: _____________________ Signature: _______________________ Date: __ / __ / __
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STUDENT ATTENDANCE RECORD

This student attendance record is to be completed by the student daily and signed by the Supervisor/Director.
Note: Work placement days should consist of 8 hours a day, totalling 80 hours (break times not included in total
hours)
Organisation:
Address:
Contact on site:
Day Date Start Finish Total Hours Student Supervisor
Time Time Completed Signature Signature
1
10
11
12
13
14
15
Total Hours Completed: 80
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STUDENT ACKNOWLEDGEMENT SECTION (to be completed by student)

Participant Statement Tick
I have received clear instructions of the assessments to be completed during my work placement.
I am aware of the evidence collection process and the role of my Trainer/Assessor.
I am aware of who my Supervisor/Manager is for all communication while completing my work placement.
I understand what will be required of me to complete a successful work placement and onsite assessment
visits with my Trainer/Assessor.
Student Comments:
Student Name: ___________________________________________
Student Signature: ________________________________________ Date: ________________
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STUDENT INSTRUCTIONS
Requirements
As a student in education and care services on work placement, you are required to keep a work placement
logbook. It is an official record of your orientation to the service, your attendance, and your understanding
of competency skills for this qualification.
Units of competency within this Logbook:
CHCECE041 Maintain a safe and healthy environment for children

CHCECE043 Nurture creativity in children
CHCECE044 Facilitate compliance in a children’s education and care service
CHCECE045 Foster positive and respectful interactions and behaviour in children
CHCECE046 Implement strategies for the inclusion of all children
CHCECE047 Analyse information to inform children’s learning
CHCECE049 Embed environmental responsibility in service operations
CHCECE050 Work in partnership with children’s families
Attendance
You will need to maintain an accurate record of your attendance while on your placement; the information in this
booklet will verify your completion of the minimum required 80 hours. Please ensure the Supervisor/Director
signs your logbook on the required pages.
Starting and finishing times will be a negotiation between yourself and your work placement centre.
Days that you are absent from work placement need to be made up.
Service Orientation
An educator will show you around the service on your first day. By the end of your first day, you are expected to
complete and sign the placement orientation checklist in this booklet. Your Assessor will request to see this at
their visit.
Student Responsibilities
You are responsible for reading and understanding this booklet outlining what is expected of you at your work
placement. If you have any questions during your placement, phone your Trainer/Assessor at the training college
on 9682 0100 or email granville@hnh.org.au. You are responsible for contacting the college or Trainer/Assessor
if you cannot attend a placement day for any reason.
• You are expected to arrive at the service 10 minutes prior to your starting time
• If you are unable to attend a day you must telephone your trainer/assessor or the college (9682 0100)
prior to your starting time to inform them of your absence and the reason, why you will not be
attending
• You must bring your own coffee mug and lunch
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Dress Code
For working safely with children, it is recommended –
o Hair should be tied back, where possible

o Stud earrings are preferred
o Small bangles or bracelets are preferred
o Nails should be kept short
o Must follow sun safety policy of service, using hat and wearing half sleeve or full sleeve t-shirt
o Track pants are not to be worn at any time
o Shoes must be closed in and have non-slip soles.
Professionalism
It is important that you maintain a professional approach in all aspects of your work placement, ensure that you
keep your personal belongings in the designated space allocated by the service. Please make sure that your mobile
phone is switched off during the duration of your work placement.
Ensure communication is always completed respectfully, courteously, and professionally.
Colleges Responsibilities
h&h staff will liaise with both the service and you throughout the placement. The college's role is to support you
throughout your placement, aiming for a successful outcome in utilising your learned skills.
Service Responsibilities
The service is required to report any difficulties you are experiencing to the college. They must also provide
support throughout your work placement. The service is required to sign off your attendance as part of your
competency towards your qualification.
At any stage of your work placement, if you are unsure of tasks or need to speak to your Trainer/Assessor, please
phone the college.
Please phone 96820100, we are here to help with all enquiries.
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INSTRUCTIONS FOR COMPLETING ASSESSMENT SECTION
Student Instructions
Students undertaking the Diploma of Early Childhood Education & Care (CHC50121), have received the
educational theory component of this certificate. These skills must now be practised and demonstrated in a
workplace environment to achieve competency.
Students will be required to list the number of children assisted during work placement. ECEC Services expect
students to have adequate knowledge and practice to demonstrate the relevant skills.
Prior to each student commencing work placement, they will have the opportunity to practice their skills in a
simulated workplace environment within the college.
h&h Assessor Instructions
The qualification requires assessments to be completed 'on the job' under normal workplace conditions, including
completing the work placement component at a Children's Education and Care Centre.
This enables students to gain access to a variety of age groups (generally pre-schools and family day care facilities
do not cater for babies in the 0-12 month age groups). Students are required to gain their experiences in various
sections of the childcare service (babies' room 0-2 years, toddlers' room 2-3 years and preschoolers 3-5 years).
Assessments are completed in a range of conditions, over several assessment situations, which can be done
through daily task observations or student workplace assessments.
A qualified h&h Trainer/Assessor will conduct an onsite assessment during placement. This is generally a 2 to 2.5
hour assessment process. The college will contact the service with the date and an approximate assessment time.
Should there be an instance when the Trainer/Assessor is unable to observe one of the daily tasks (this could be
due to time of day, child refusal, etc) the Certified/Nominated Supervisor must complete the third-party
observation section, stating the skill has been demonstrated satisfactorily.
Service Certified/Nominated Supervisor (Third Party) Instructions
During the student's 80-hour placement, the service has an opportunity to observe the skills and knowledge the
student has gained during their theory and online/classroom practice. The college would appreciate your feedback
in the third-party observation section.
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Daily Reflections Activity - While on work placement, you must outline what tasks you performed during
the day and elaborate on one of these tasks. (To be completed for 10 days).
Some suggestions to consider each day for your entry may include:
• Reflection on what you did to maintain a safe and healthy environment for the children
• What you did to nurture the creativity of the children, while implementing strategies for the inclusion of
all of the children
• Reflection on the various interactions with the children and their families, and how you fostered positive
and respectful interactions
• Identified areas where you would like to further develop your skills
• Demonstrating environmental responsibility to the children, while acknowledging the environmental
practices of the facility
• How you used the information available to inform the children’s learning
• How you were involved, and worked, with the children’s families
Day 1
Morning:
Afternoon:
Elaboration on one of the tasks described above:
Day 2
Morning:
Afternoon:
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Day 3
Morning:
Afternoon:
Day 4
Morning:
Afternoon:
Day 5
Morning:
Afternoon:
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Day 6
Morning:
Afternoon:
Day 7
Morning:
Afternoon:
Day 8
Morning:
Afternoon:
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Day 9
Morning:
Afternoon:
Day 10
Morning:
Afternoon:
Note - A little guidance on reflections for students
Why is reflection important in the workplace?
Reflection can help you to:
• identify the type of experiences and abilities you already have

• identify those areas you are likely to need, to become more employable
• identify your strengths and weaknesses
• identify when you have been in specific situations, what you did and how can do it differently next time
• identify how you can effectively communicate from experiences you have had.
From the team at h&h
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STUDENT WORKPLACE ASSESSMENTS

This workbook is designed to complement the theory component of Diploma of Early Childhood Education & Care
(CHC50121), which you have completed. To be assessed as competent, students must (under the guidance of h&h
qualified trainers and assessors) demonstrate the ability to perform all required skills and knowledge in a variety
of simulated and workplace situations.
In completing all facets of these assessments, you will be fulfilling the practical component of this qualification.
For further information on all aspects of the training package relating to your qualification. You can access
information at: https://training.gov.au/Training/Details/CHC50121
h&h Trainers and Assessors follow the guidelines below to judge evidence suitably:
• Valid (an assessment is valid when the process is sound and assesses what it claims to assess)
• Sufficient (relates to the quantity and quality of evidence assessed)
• Currency (relates to the age of evidence presented by the student to demonstrate competency)
• Authenticity (ensures the student has submitted their own work)
Assessments throughout this unit can be assessed independently; however, holistic assessment practice is
encouraged by h&h while on work placement, which includes a variety of units within a single assessment task.
Resources required for assessment of this qualification include access to a range of opportunities, including:
• Education and care services

• Resources and equipment
• Local environment
Reasonable adjustments can be made to ensure equity in assessment for all students. Please refer to your student
handbook for further information on reasonable adjustment, or speak to the training college on 9682 0100.
This booklet consists of the responsibilities the educator has for designing and implementing curriculum that
meets the requirements of the learning framework, while maintaining compliance in other areas of service
operations. The compliance areas may relate to diverse work situations, adequate supervision, analysis of
concepts to meet compliance.
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ASSESSMENT ITEM 1:
CHCECE041 - Using policies and procedures to maintain a safe and healthy environment for children
(a) You will examine existing service policies and procedures and support materials, and document how risks
are addressed in each of the following areas:
- health safety and wellbeing
- incidents, injury, trauma, and illness
- infection control
- medical conditions
- administration of medication
- emergencies and evacuations
- drop off and collection of children
- supervision
You will choose three of the policies listed above, examine them at the facility, and then reflect on the concept of each of the
chosen policies, explaining how risks are addressed in each one.
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(b) Once you complete the first item, you need to choose one of your three policies and from that add one document
(or one piece of supporting material) that may be used by educators, as it forms part of that particular policy, you
will include why it is part of the policy and of what benefit it is to the organisation and stakeholders. For example, a
policy that covers incidents, injury, trauma, and illness, has an Incident and Injury Form as a document that is part
of the policy. Write you response below:
(c) You and your colleagues are planning an excursion to the local community play park. You need to develop
a Risk Management Plan for the excursion. The Plan will be established according to the policies and
procedures of the service. The plan will also include any legislative requirements. In point form outline
the plan you will implement, stating why each point is relevant. Write you response below:
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Student Notes:
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ASSESSMENT ITEM 2:
CHCECE043 – Developing creativity in children
(a) You will plan and implement three experiences for children between the ages of birth and six years that
collectively involve all the following:
- construction
- digital technologies
- dramatic play
- imaginative play
- language and storytelling
- movement
- music
- science, technology, engineering, arts, and maths (STEAM)
- visual art
Describe the three experiences using the activities and ‘performances’ listed above. You must elaborate, giving
information on your chosen experiences, clearly demonstrating how they support the various children’s age
development:
1.
2.
3.
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(b) Describe how you implemented each experience. Explain in detail:

- How you first communicated with the children?
- How you explained the concept of the activity or play experience?
- Include the resources you used to make this activity ready for children in various age groups
(c) You will now document the evaluation outcomes for each of the planned experiences. You will explain
how the evaluation outcomes were documented for each of the experiences, specifying the methods
used, e.g. Self-reflection method, daily journal method, project/experience report.
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Student Notes:
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ASSESSMENT ITEM 3:
CHCECE044 - Ensuring compliance is adhered to within the education and care environment
In the context of your job role, you will facilitate self-assessment and development of a quality improvement plan
(QIP) for two quality areas within the education and care service.
(a) List below your understanding of the process of (self) assessment within the ECEC service. In point form
list how you would facilitate the assessment. For example, you could provide evidence of the seven quality
areas of the NQS, then recognise areas of strengths and areas that need improvement within the practice.
(b) Describe how you would develop a Quality Improvement Plan for two quality areas? Choose the desired
elements, provide examples of the service philosophy, outcomes and goals being sought. You will include
the priority level of the plan, and what constitutes a measure of success for the QIP.
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Student Notes:
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ASSESSMENT ITEM 4:
CHCECE045 – Developing guidelines that foster positive and respectful interactions and behaviour in children
You will observe the social interactions of children on three occasions and identify:
- emerging pro-social skills
- strategies you would use to support the development of pro-social skills
You will then complete the following for two different children who require assistance with self-regulation and
pro-social skills:
- review any pre-existing information regarding the child’s interactions and behaviour
- review physical and social environment within and outside the service and identify impacts on child’s
behaviour
- observe and monitor the interactions and responses of the child to identify challenging behaviour
- participate in two collaborative discussions about the child’s interactions and behaviour with colleagues
- document own reflection on the gathered information
- develop, implement, and evaluate a support plan for the child in collaboration with colleagues
• For this task, you may have one focus child or a few focus children; basing your observations on pro-social
skills
• You will list the strategies you used to support the development of their pro-social skills e.g. you may focus
on the sociogram of one child or a few children within the group)
• Your observation will need to have a review plan or a support plan, which is based on the observations
made for the focus child or a few focus children’s social life, e.g. you may create a simple structure of
follow ups where you can then monitor and review the child’s social observation during their activities
and experiences
Note: this assessment will require your response to be set out on extra pages. Please attach your work to this
booklet, clearly stating your name and the assessment task (i.e. Task 4 CHCECE045)
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Student Notes:
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ASSESSMENT ITEM 5:
CHCECE046 - How to go about implementing strategies for the inclusion of all children
You will use critical reflection to evaluate three different areas of practice in the service in terms of how they
support inclusion and inclusive practices
In your response you will promote inclusion in each of the following contexts on at least one occasion:
• curriculum development
• interpersonal communication
• develop, implement, and review a plan for support and inclusion for at least one child
1. You will choose a child with additional needs, e.g. language barrier, physical needs, etc. You need to create
three different activities and demonstrate how you would support the inclusion of the child in your
practices and activities.
Child (a)
Child (b)
Child (c)
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2. You will now create a simple inclusion support plan for the child, using as the illustration one of the
additional needs examples.
3. You now need to demonstrate how you are going to promote, develop, implement, and review your
inclusion plan in your curriculum, and how you are going to communicate the inclusion practice with
others (families, educators and other third parties, if applicable)
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Student Notes:
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ASSESSMENT TASK 6:
CHCECE047 – Demonstrating the need to analyse information to inform children’s learning
For this assessment you are required to gather, document, and analyse information about an individual child on
six different occasions using a minimum of three different tools or methods. You will use the following tasks to
develop and document a perspective about the child’s:
• overall development
• knowledge
• ideas
• strengths
• interests
• social interactions
• reactions to play environment
• report on two different critical reflection activities used to review own practice
1. You will need to choose two observations for three different age groups (0-2), (2-4) and (3-5), using various
methods or records for observations, e.g. anecdotal record, photo sequencing, event sample, or video
recording (with permission)
2. Have your observation records based on children’s age development, interests, and needs
3. Create two self-reflection reports where you can review the activities or your practices which you have
observed the children in
Note: this assessment will require your response to be set out on extra pages. Please attach your work to this
booklet, clearly stating your name and the assessment task (i.e. Task 6 CHCECE047)
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Student Notes:
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ASSESSMENT TASK 7:
CHCECE049 - Embedding environmental responsibility into the service operations
In this assessment you will observe and document three examples of practices that demonstrate children’s
understanding of environmental responsibility. You will also:
• review service operations in line with contemporary practices
• consult with stakeholders
• identify opportunities for improvement
• document outcomes of implementation
• share outcomes and evaluation of plan implementation with a supervisor
1. You need to create 3 experiences with children between the age of (2-5 yrs). Your experience should be based on
sustainability practice and environmental responsibility.
2. You may need to consider having a plan, where you can reflect on the activities provided for children and must be
age appropriate.
3. Your plan must be designed, implemented, and evaluated in line with service’s environmental practices and
responsibility (for example: you may consider having a learning session or an activity that refer to sustainability in
using the correct recycling processes, or the correct usage of water etc).
4. Once the steps of your plan are developed, you need to provide evidence of documentation which reflects the
outcomes of your activities and then share your outcomes and evaluation of your practice with relevant people in
the workplace (Supervisor, room leader or members of families).
Note: this assessment will require your response to be set out on extra pages. Please attach your work to this booklet,
clearly stating your name and the assessment task (i.e. Task 7 CHCECE049)
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Student Notes:
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ASSESSMENT ITEM 8:
CHCECE050 - Working in partnership with children’s families
In this task you are required to work with two different families, with at least two communications per family, to
support education and care using all the following:
• active listening
• collaborative discussion and decision-making
• provision of clear verbal information
• questioning
• negotiation
a) You need to approach two different families with the permission of your supervisor or director with a
simple questionnaire that you have created, you will have chosen at least two communications per family.
b) You may exchange information with families about their child’s:
- Progress
- Relationships
- Interests
- Experiences
c) Your conversation must be either voice recorded/video recorded, where you demonstrate active listening
skills and clear verbal communication skills (questioning and negotiating).
Student sought permission from a supervisor.
Supervisor Name: Supervisor Signature:
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Student Notes:
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WORK PLACEMENT OVERALL FEEDBACK (to be completed by h&h Trainer/Assessor)
Tick
h&h Trainer/Assessor Declaration:
I have discussed the student's assessment items with the student during, and prior to, onsite
assessment
I can confirm that the student has attended work placement for 80 hours
The student demonstrated the skills required as per units of competency
Onsite visit log has been completed (submitted through JotForm/hardcopy)
Assessor Comments:
Satisfactory: □ Unsatisfactory: □
Assessor Name:
Assessor Signature: Date: ___________
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Work Placement Booklet 1

Long Day Care

Student Email Address:

h&h Accredited Training

Work Placement Overview

I __________________________________________ (Trainer/Assessor) verify that the student has demonstrated

Trainer / Assessor Signature: Date / /

INSTRUCTIONS TO THE ORGANISATION HOSTING OUR h&h STUDENT

The hosting organisation is required to complete the following sections ONLY.

1. Observation Permission – Third Party Declaration

Thank you again,

THIRD PARTY DECLARATION (to be completed by the Supervisor/Manager) Tick

I, _____________________________ (supervisor name) have provided permission to this student, to have

Supervisor/Manager Signature: _____________________________ Date: ___/___/____

Page intentionally blank

SUPERVISOR FEEDBACK (to be completed at the end of work placement)

Checklist Completed Comments

The student went through an orientation/induction on their first □

The student has a clear understanding of the work role in early □

The student is communicative when there is a lack of □

The student provided assistance with daily tasks such as nappy □

Supervisor/Manager Signature: _____________________________________________ Date: ___/___/____

Page intentionally blank

ORIENTATION CHECKLIST (to be completed by Supervisor/Manager)

1. Participated and gathered information on the following:

o Undertaken a tour and physical orientation of the service

2. Located the evacuation and fire safety policy and procedures:

o Extinguishers/fire blanket location

3. Identified the emergency response procedure:

o In the event of an emergency, I am aware of the emergency phone number/call sign

4. Located the infection control policy:

o I understand the procedure for managing a spill (eg. water)

5. Located the incident, accident and complaints reporting procedure:

Student Name: __________________________ Signature: _______________________ Date: __ / __ / __

Supervisor/Manager: _____________________ Signature: _______________________ Date: __ / __ / __

Page intentionally blank

STUDENT ATTENDANCE RECORD

Total Hours Completed: 80

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STUDENT ACKNOWLEDGEMENT SECTION (to be completed by student)

I am aware of the evidence collection process and the role of my Trainer/Assessor.

Student Name: ___________________________________________

Student Signature: ________________________________________ Date: ________________

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Units of competency within this Logbook:

CHCECE041 Maintain a safe and healthy environment for children

For working safely with children, it is recommended –

o Hair should be tied back, where possible

Ensure communication is always completed respectfully, courteously, and professionally.

Please phone 96820100, we are here to help with all enquiries.

INSTRUCTIONS FOR COMPLETING ASSESSMENT SECTION

h&h Assessor Instructions

Service Certified/Nominated Supervisor (Third Party) Instructions

Page intentionally blank

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Elaboration on one of the tasks described above:

Supervisor/Manager Signature: ___________________________ Date: _/_/__

Supervisor/Manager Signature: ___________________________________________ Date: _/_/__

Student Name: ______ Signature: _ Date: / /

Supervisor/Manager: _ Signature: _ Date: / /

Student Signature: ________________________ Date: