PEX Practicum Student Application Form

PEX Prac Student Application Form

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PEX Practicum Student Application Form

EDMUND RICE COLLEGE

PEX Practicum Student Application Form

Please complete the ‘PEX Practicum Student Application Form’ to apply for placement at Edmund Rice College.

Please ensure all information is correct and up to date. If at any stage you need to stop completing the application before submission, please use the “save and continue” button at the bottom of the form.

For further enquiries, please contact the Human Resources Manager via jthomas@erc.nsw.edu.au or on (02) 4228 4344.

PEX Practicum Student Application Form

Position Type:(Required)

Practicum Student

University:(Required)

Placement start date:(Required)

DD slash MM slash YYYY

Placement end date:(Required)

DD slash MM slash YYYY

Teaching Department/s:(Required)

Personal Details

Title (Mr, Mrs, Ms, Miss, Dr):(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email:(Required)

Date of Birth:(Required)

DD slash MM slash YYYY

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Working With Children Check (WWCC)

This position is child-related work; you must obtain a Working with Children Check Clearance number from ServiceNSW. You are not permitted fro placement at Edmund Rice College until you provide the College with your WWCC number and it has been verified.

Do you hold a WWCC?(Required)

Yes

WWCC number:(Required)

Application number:

Date of application:

DD slash MM slash YYYY

Health & Employment

Applicants are asked to complete all of the 'Health & Employment Declaration' and to provide any supporting or explanatory material. The information is necessary in order to assess each applicant’s eligibility for placement. This information is confidential. If the space below is sufficient, please attach separate documentation.

Do you have any current health problems, which may impact on your capacity to carry out the duties of a Practicum Student?(Required)

Yes

Please provide details:(Required)

Are you taking regular medication prescribed by a medical practitioner, which may impact on your capacity to carry out the duties of a Practicum Student?(Required)

Yes

Please provide details:(Required)

Health & Employment Declaration(Required)

By submitting this application, I am agreeing to the following:

(1) I understand that if further medical information is required, I may be asked to give written authorisation for Edmund Rice College to seek medical information.
(2) I acknowledge that all information provided in support of these responses are true and correct in every respect, and any wilful suppression or inaccuracy may result in non-acceptance of this application and/or termination of placement.

Child Protection & Professional Conduct

Have you ever been accused of physically, sexually or emotionally abusing a child or a young person?(Required)

Yes

Please provide details:(Required)

Have you ever been the subject of an allegation of ‘reportable conduct’ (that is: sexual offence, sexual misconduct, assault, ill-treatment, neglect or psychological harm of a child or young person) as defined by the NSW Office of Children's Guardian?(Required)

Yes

Please provide details:(Required)

Have you ever been the subject of a complaint/allegation and/or internal investigation that related to a breach of your professional boundaries and/or breach of a Code of Conduct?(Required)

Yes

Please provide details:(Required)

Are you aware of any reason or concern, held by another person, which may make you unsuitable to work in child-related employment?(Required)

Yes

Please provide details:(Required)

Have you ever been the subject of an Apprehended Violence Order (AVO) that was made for the purpose of protecting a child or young person from harm?(Required)

Yes

Please provide details:(Required)

Have you ever been charged and/or convicted with any criminal offence?(Required)

Yes

Please provide details:(Required)

Are you a parent or close relative of a student currently enrolled at Edmund Rice College?(Required)

Yes

Please provide details:(Required)

Proof of Identity

Identification Documents

1. ‘100 point’ proof of identity (e.g. drivers licence, passport, birth certificate, Medicare card)

File Upload(Required)

Drop files here or

Max. file size: 512 MB.

Please upload your IDENTIFICATION DOCUMENT/S.

APPLICANT DECLARATION

Consent(Required)

By submitting this application, I am agreeing to the following::

(1) There is no reason for Edmund RIce College to believe I am not suitable for placement in child-related work. If any information not disclosed in this application is brought to the attention of the College, my application may be reviewed and/or placement may be terminated.
(2) I am aware of my obligations under the Child Protection (Working with Children) Act 2012 to notify the College of any changes to my Working with Children Check Number status or to any change to my personal circumstances that would preclude my placement in child related work.
(3) The information provided in this application form is complete and correct in every detail, and I understand that deliberate inaccuracies or omissions may result in non-acceptance of my application and/or termination of placement.
(4) I agree to respect, support and uphold the mission, ethos and teachings of the Catholic Church and the values of Edmund Rice College.
(5) I agree to complete all necessary Edmund Rice College compliance modules prior to my placement commencing at the College.

Date(Required)

DD slash MM slash YYYY

Name(Required)

First Last

Signature(Required)

Visit Us

Address

Email

Phone

Fax

Hours

PEX Prac Student Application Form

PEX Prac Student Application Form

PEX Prac Student Application Form

PEX Prac Student Application Form

PEX Prac Student Application Form

PEX Prac Student Application Form

PEX Prac Student Application Form

EDMUND RICE COLLEGE

PEX Practicum Student Application Form

PEX Practicum Student Application Form

Personal Details

Emergency Contact

Working With Children Check (WWCC)

Health & Employment

Child Protection & Professional Conduct

Proof of Identity

APPLICANT DECLARATION