Work Placement Registration Form

2. Service / Section *

3. Name of Trainee

4. Name of Sponsor *

5. Trainee Contact Details *

Home Address	*
Address
Town / Village	*
Post Code	*
Contact Number	*
Contact Email

6. Emergency Contact Details *

Name	*
Relationship to Trainee	*
Contact Number	*
Address (if Different from trainee)

7. Proposed Start Date *

	DD/MM/YYYY

8. Proposed End Date *

	DD/MM/YYYY

9. Health & Safety Checklist (It is the responsibility of the Service to ensure that an appropriate Risk Assessment is undertaken and suitable measures; information; equipment provided)

Check Completed by *

Chamber of Commerce
Skills Development & Employability Service

Placement Sponsor (Trainee must be 16 years or over)