Work Experience Information and Consent form - Our Tesco

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Work Experience Information and Consent form

Section 1 - INFORMATION ABOUT THE STUDENT Name of Student: ____________________________________________DOB: __________________ Address: __________________________________________________________________________________________

Post Code:______________ Tel. No:___________________________ Name of Emergency Contact:________________________________________________________________________________ Emergency Contact Tel. No:-________________________

Name of School: ______________________________________ Telephone Number of School:__________________________________

Essential Information relevant to Health, Safety and Welfare In order for us to provide a safe placement it is essential that any medical or other significant information that may affect your son/daughter’s health and safety is provided. Please give any relevant details:Has your son/daughter have any health problems that may affect their safety and welfare, including the need for regular medication? If so please outline the details:

Any other information you would like to make aware of that could affect the health, safety and welfare of your son/daughter:

I agree that the above information can be seen by the company and that the school (if required) can disclose any information that they feel is relevant to the health, safety and welfare of my son/daughter whilst on a work experience placement.

Signature of Parent/Carer:___________________________________________Date:______________

Signature of Student:_______________________________________________Date:______________

__________________________Internal, Work Experience Information and Consent form, Version 1, Page 1 of 2

June 2016

Section 2 - ABOUT TESCO AND THE PLACEMENT Name of office/store: _______________________________________________________________________ Address __________________________________________________________________________________________ Post Code: _______________________ Main Contact (Tesco colleague arranging the placement) _______________________________ Job Role/ Position_______________________ Main Contact Telephone No: ____________________ Mobile No:-____________ ____ Email: ____________________________

ABOUT THE PLACEMENT Days of Work (please circle): Mon Tues Wed Thurs Fri for 1 week or 2 weeks Hours of Work: __________________________________________________________________________________________ Dress code or special clothing required:________________________________________________________________________ Placement Start Date:_________ End Date:_________

Signature of main contact:___________________________________________Date:______________

__________________________Internal, Work Experience Information and Consent form, Version 1, Page 2 of 2

June 2016