CiviCRM -

Full Name *

Date of Birth *

Address *

Postcode *

Phone *

Email *

School/College *

Year Group / Course *

Name of Teacher / Placement Coordinator *

Contact Details of School/College *

Preferred Start Date *

Preferred End Date *

Total Number of Days / Hours Required *

Type of Placement *

Areas of Interest (Tick all that apply) *

If you selected "Other", please specify

Why would you like to complete your placement at KGV Community Centre? *

What skills or experience do you already have that might help you during your placement? *

What would you like to learn or gain from this experience? *

Do you have any medical conditions, allergies, or support needs we should be aware of? *

No Yes - please provide details

If yes, please provide details

Emergency Contact Name *

Relationship to Student *

Emergency Contact Number *

Alternative Contact Number

Name of Parent/Guardian *

I consent to my child applying for a placement at KGV Community Centre *

Yes No

Date of Consent *

I confirm the information provided is accurate and I agree to follow the policies and guidance of the KGV Community Centre during my placement *

Yes No

Student Placement Information