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Application Form

Name:

Position:

School/College:

Email:

Tel:

Fax:

Address:

Type of School:

Please tick any of the following groups to which you belong:

Member of Senior Management Team

Careers Staff

Maths

Vocational Subjects (GNVQ and new GCSEs)

Science

English

ICT

Other Group:

Name of Headteacher:

Name of Professional Development Co-ordinator:

Name of Line Manager:

What Key Objectives do you have for your placement?:

What are they linked to:

Management skills and knowledge

Personal development only

Curriculum development

IT skills

Within your schooll/college which of these impact areas are most likely to be affected by your placement?:

Standards of achievement

Pupil motivation and attendance

Management and leadership

Preparing young people for the world of work, including employability

Delivery of the National Curriculum

Delivery of key skills, including wider skills such as creativity and enterprise

HEALTH FORM:

Colour Blindness

Dizziness

Epilepsy

Fainting or Blackouts

Impaired Hearing

Impaired Eyesight (if not corrected by glasses)

Inflammatory Joint Condition

Asthma

Eczema / Dermatitis

Back Problems

Claustrophobia

Skin Problems

Mental Health Problems

Physical Disabilities

Are you taking any medication that may affect your work, i.e. cause drowsiness?

If you suffer from any of the following potential health problems please indicate by ticking the appropriate circle and sign as requested.

If you have indicated YES for any of the above or if you have a medical condition that has not been listed please give further information in the space provided below:

Education Business Plus, 2 The Stables, Gadbrook Park, Northwich, CW9 7RJ, Tel: 01606 305 210, Fax: 01606 491 158

Education Business Plus is part of Connexions - Cheshire & Warrington Limited