Student Placement Request Form
This form is to be completed by students who are studying a relevant degree that contains a mandatory placement component to satisfy curriculum learning and study outcomes and interested in undertaking a placement within the Department of Communities, Child Safety and Disability Services. Please complete all fields of this form and send it to the Work Experience Mailbox (workexperience@communities.qld.gov.au) along with copies of your:
•	current resume and; 
•	Blue/Yellow card/s where applicable. 

All students over the age of 18 will be required to undergo a criminal history screening process prior to starting a placement.

Please note that we cannot guarantee availability of a suitable placement
Section 1 – Eligibility Requirements 
Are you an Australian Citizen or Permanent Resident?     
Yes     ☐     No     ☐
Are you currently enrolled in a degree course in an education or training course with an Australian Registered Training Organization?     
Yes     ☐     No     ☐ 
Is the placement you are seeking a mandatory and assessable part of your study?
 Yes     ☐     No     ☐ (please see refer to our work experience request form)
Are you covered by appropriate insurance by your education provider and can you provide a copy of their Certificate of Currency to verify this prior to commencing a placement?
Yes     ☐     No     ☐
If you answered ‘No’ to any of the above question you are not eligible to undertake a student placement with the Department of Communities, Child Safety and Disability Services. 

Section 2 - Personal Details
Full Name: ______________________________________________ Date of Birth: _______________ 
Address: __________________________________________________________________________
Postcode: ____________________ Contact Number: ______________________________________
Email Address: _____________________________________________________________________
Are you over the age of 18?     Yes     ☐     No     ☐
If you are under 18 years of age your parent or guardian must complete the parent/guardian consent in ‘Section 6’ of this request form for your application to be considered. 

Section 3 – Education Institution & Course Details 
Institution Name: _______________________________________________________________
Address: ____________________________________________________________________
Contact Name: _______________________________________ Phone: ______________________
Contact Email Address: ______________________________________________________________
Course name: ________________________________________________________________

Section 4 - placement details
1.	How many hours/days are you required to complete?  Click here to enter text.
2.	What type of placement are you seeking?  
☐ Part time (i.e. 1 day per week over several weeks)               ☐Block Periods
3.	Briefly outline the specific work or study requirements for this placement:
Click here to enter text.
4.	Please list you three most preferred work placement locations:
1.     Click here to enter text.
2      Click here to enter text.
3.     Click here to enter text.
For further information on the Service Centre locations, please visit the department’s website: http://www.communities.qld.gov.au/gateway/about-us/contact-us (go to the relevant link under “Regional Service Centre – Key Contacts’).
5.	 Please select the most relevant area of interest for your placement:
       	 ☐   Child Safety                                                        ☐   Human Resources 
     		 ☐   Disability Services                                              ☐ Financial Services
 ☐   Community Care                                                ☐   Other (please specify)
     		 ☐   Information Technology                                          Click here to enter text.
6.	Do you wish to undertake a placement working with children (0-18 years of age)?  
Yes     ☐     No     ☐ 

If ‘yes’, you must provide a copy of your current Blue Card when you submit this application for you request to be considered.

7.	Do you wish to undertake a placement at a departmental disability service outlet? 
Yes     ☐     No     ☐ 

If ‘yes’, you must provide a copy of your current Yellow Card when you submit this application for you request to be considered.
Section 5 - Availability
From what date are you available to commence the placement:     Click here to enter text. 
Which days will you be available?
☐ Monday       ☐ Tuesday          ☐ Wednesday         ☐ Thursday          ☐ Friday

Section 6 – Parent/Guardian Details & Consent
Full name: ______________________________________ Relationship to child: _________________
Address: ________________________________________________________________________
_________________________________________________ Postcode ___________________
Phone: ____________________________ Email: ______________________________________

I (full name of parent) __________________________________________________________
Of (address)________________________________________________________________________
_________________________________________________ Postcode ___________________
give my permission for (full name of child) _______________________________________________
to undertake a vocational student placement with the Department of Communities, Child Safety and Disability Services. 

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(Signature)

____ /____ / ____
(Date)