Application for Work Placement

Completion of this form does not guarantee a Work Placement.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of application {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Current place of study (University/College) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Qualification currently studying {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tutor details

Tutor name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tutor Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tutor Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Total number of work placement hours required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Preferred starting date for your work placement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please provide details as to why you wish to complete your work placement with Community Living Australia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Driver's licence details

Do you have a current driver's license? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Driver's Licence Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Driver's Licence Expiry Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you willing to use your vehicle (subject to approval) as part of your work placement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any restrictions on your licence? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please provide details of restriction: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you hold any of the following

A current DHS Disability Services Employment Screening Clearance or NDIS Worker Check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

A current DHS Child-Related Employment Screening or Working With Children Check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

A current First Aid Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

A current CPR Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

A current Safe Environments for Children and Young People Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you undertaken the DCP psychometric screening to work within Children’s Services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you willing to obtain those you answered no to at your own cost prior to commencing employment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you currently live with a disability that may impact your ability to fulfil the full duties of a Support Worker role. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes, please list any duties that you may not be able to undertake and/or modifications required to fulfill the Support Worker role. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Where did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Working region (tick all regions that you are available to work in): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Shift Availability (please tick all shifts you are available to work)

Monday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tuesday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Wednesday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Thursday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Friday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Saturday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sunday {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of service preferred: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please attach a copy of the following documents (if available)

Work placement insurance documents from your University/College {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Workplace Agreement from your University/College {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Current DHS Disability services Employment Screening {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Current DHS Child Related or Working with Children Check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Current Driver's Licence {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Current First Aid Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Current CPR Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Child Safe Environments Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Declaration by Applicant

I declare: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Application for Work Placement

Tutor details

Driver's licence details

Do you hold any of the following

Shift Availability (please tick all shifts you are available to work)

Please attach a copy of the following documents (if available)

Declaration by Applicant

Application for Work Placement

Your progress has been saved.

Application for Work Placement

Tutor details

Driver's licence details

Do you hold any of the following

Shift Availability (please tick all shifts you are available to work)

Please attach a copy of the following documents (if available)

Declaration by Applicant