Work Experience Arrangement Form

Education and Training Reform Act 2006 – Ministerial Order 1413:

Work Experience Arrangements (Schools)

STUDENT DETAILS
Surname First Name Birth Date / /
School Name and Address Mazenod College, Kernot Avenue, MULGRAVE 3170 VIC
MULGRAVE VIC Postcode 3170 Telephone (03) 9560 0911
Work Experience Coordinator Vivian Seremetis (E): [email protected] Student Year Level
IN CASE OF AN EMERGENCY, THE EMPLOYER SHOULD CONTACT THE STUDENT’S PARENT OR GUARDIAN AND
THE WORK EXPERIENCE COORDINATOR:
Name (Parent/Guardian)
Address Postcode
Tel. (Home) (Work) (Mobile)
Emergency contact (Name and Tel.) Student Mobile
PRIVACY INFORMATION: The information provided on this form is for the administration of Work Experience
Arrangements only and is not to be used for any other purpose. Health information will be provided if the Student has
a medical condition or requires medication that may be relevant to their placement. This information must be kept
confidential.
WORK PLACEMENT DETAILS
Employer (business) name Tel.
Business address Postcode
Employer email address ___________________________________________________________
Type of industry Primary activity at workplace
Student’s work location address Postcode
Workplace contact person Supervisor
Activities the student will undertake (if insufficient space, attach separate sheet)

Work Experience hours am / pm, to am / pm; on  Monday  Tuesday  Wednesday  Thursday  Friday
from (commencement date) to (completion date) Total number of days
If insufficient space for dates and hours, please attach additional sheet.
Rate of payment $ per day ($5.00 per day minimum)

EMPLOYER ACKNOWLEDGEMENT (Employer to sign)

I, [name of individual, or on behalf of the Employer if Employer is an incorporated body] agree that:
1. I understand occupational health and safety legislation and standards relevant to the conduct of my undertaking and will
comply with these laws and standards with respect to the Student as if the Student were my employee.
2. I will identify all hazards relevant to the conduct of my undertaking and will assess and control all related risks. If I have not
controlled all related risks I will inform the school of this fact prior to the Work Experience Arrangement commencing.
3. I have read and understood the Department of Education Work Experience Guidelines for Employers. I will ensure that
required planning, induction, supervision and safe systems of work are provided for the Student to maintain a safe and healthy
Work Experience Arrangement at all times.
4. I will consider and take into account the competency, maturity and physical capabilities of the Student in relation to all activities
they will undertake. The Student’s program of activities will be planned and carried out with these considerations in mind.
5. I will nominate a Supervisor (or Supervisors) of the Student who will be responsible for ensuring that my obligations as the
Student’s Employer are carried out.
6. I will provide appropriate information, training, instruction and supervision to the Student in respect of occupational health
and safety and will provide any equipment and/or clothing which is required to comply with my duty of care toward the Student.
7. I will ensure that the Work Experience is undertaken in a non-discriminatory and harassment free environment.
8. I will permit access to the workplace and contact with the Student by the Principal or the Work Experience Coordinator at any
reasonable time during the Work Experience Arrangement.
9. I will ensure that the Work Experience Arrangement is not used as a substitute for the employment of employees or the
engagement of contractors and the payment of appropriate wages or fee for services to employees or contractors
respectively.
10. I will ensure that the maximum number of students in the workplace does not exceed one Student for every three employees.
11. If I have sought to engage more than the permitted number of Work Experience Students, I confirm that direct supervision
will be provided for all Students.
12. Where the Principal has disclosed any necessary health information in relation to the Student I confirm that I will maintain the
confidentiality of that health information and only disclose this information to another party if treatment is required for a known
medical condition or in the case of a medical emergency.
13. I will notify the Work Experience Coordinator as soon as is possible if the Student is absent, injured or becomes ill in the
course of undertaking the Work Experience.
14. I will consult with the Principal if I consider it necessary to terminate the Arrangement before the specified time.
15. I will advise the Principal if the industry to which this Arrangement relates includes potential exposure of the Student to
scheduled carcinogenic substances and/or other hazardous substances as defined in the Occupational Health and Safety
Regulations 2017.
16. I acknowledge the requirement for the Student to be paid in accordance with section 5.4.9 of the Education and Training
Reform Act 2006.
If the Student is a Child (under 15 years of age): 
1. I confirm that any proposed Supervisor has a current Working With Children (WWC) clearance issued under section 68 of
the Worker Screening Act 2020 and will provide certified copies of these to the Principal.
2. I will advise the Principal immediately if there is a relevant change in circumstances with respect to a Supervisor as specified
in section 72 of the Worker Screening Act 2020 including, if the Supervisor is charged with, convicted of or found guilty of a
relevant offence, becomes subject to reporting obligations, an extended supervision order, supervision order, detention order
or if a relevant finding is made against the Supervisor.
3. I will notify the Principal immediately if a Supervisor receives written notice from the Secretary to the Department of Justice
and Community Safety that the Secretary proposes or is required to revoke the Supervisor’s WWC Clearance or has revoked
the Supervisor’s WWC clearance and has given the Supervisor a WWC exclusion.

I understand and accept the responsibilities set out above. Following the Principal’s review of these details, I understand that they
will determine whether or not the Student will undertake the Work Experience Arrangement proposed here.

Signature Date / /

STUDENT AGREEMENT
I, _______________________________________________ agree to take part in this Work Experience Arrangement and to:
 do all the reasonable and lawful activities the Employer asks me to, and to do my work to the best of my ability;
 follow all the reasonable workplace rules and requirements that relate to safety and behaviour;
 attend the workplace on each day at the agreed time;
 tell both the Employer and the Work Experience Coordinator as soon as possible if I am unable to attend work;
 promptly inform the Employer of any accident, injury or incident that may happen;
 dress appropriately for the workplace;
 agree that no payment will be made to me if the placement is with a Commonwealth Department or a body established under
a Commonwealth Act;
 where the placement is with an organisation that is engaged wholly or mainly in an educational, charitable or community
welfare service that is not for profit and where I have determined that the whole of my payment will be donated back to the
organisation, agree to donate payment back to that organisation;
 agree that prior to starting the placement, I will complete the occupational health and safety program required by the
Department of Education.
Students aged 18 years and over:
 I consent to the release of any necessary health information about me by the Principal to the Employer, for which the Principal
is aware of and may disclose pursuant to the Health Records Act 2001 (Vic).
 I also agree to inform the Employer of any necessary medical information, including details of any known medical condition
which may affect me and any medication or treatment which may be relevant.
 I understand that I am responsible for my transport to and from the workplace.

I understand that the Principal will determine whether or not I will undertake Work Experience.

Student’s signature Date / /

PARENT/GUARDIAN AGREEMENT AND CONSENT (Not required if the student is aged 18 years or over)
I, _______________________________________________ consent to my child taking part in this Work Experience
Arrangement and I:
 agree that they will be subject to the direction and control of the Employer and nominated Supervisor(s);
 understand that all reasonable care for the health and safety of my child will be taken by the Employer and nominated
Supervisor(s);
 expect my child to follow all the reasonable workplace rules and requirements that relate to safety and behaviour;
 understand that I am responsible for my child’s transport to and from the workplace;
 agree that no payment will be made to my child if the placement is with a Commonwealth Department or a body established
under a Commonwealth Act;
 give my consent to my child donating back payment where the placement is with an organisation that is engaged wholly or
mainly in an educational, charitable or community welfare service that is not for profit and where my child has determined that
the whole of their payment will be donated back to the organisation;
 understand that I will be notified as soon as possible in the event of illness of or accident to my child, but where it is impracticable
to communicate with me I authorise the person in charge at the workplace of the employer to consent to my child receiving
such medical and surgical treatment (including the administration of an anaesthesia) as may be deemed necessary by a legally
qualified medical practitioner, and administer such first-aid as is judged to be reasonably necessary;
 attach details of any known medical condition which may affect my child, and any medication or treatment which may be
relevant;
 give my consent to the release of any necessary health information in relation to my child by the Principal to the Employer, for
which the Principal is aware of and may disclose pursuant to the Health Records Act 2001 (Vic).

I understand that the Principal will determine whether or not my child will undertake Work Experience.

Signature  Parent or  Guardian Date / /

WORKSAFE INSURANCE AND PUBLIC LIABILITY INSURANCE

The Student is covered for WorkSafe Insurance by the Department of Education (State of Victoria). The Student is covered by
public liability insurance in accordance with Ministerial Order 1413 – Work Experience Arrangements, for the arrangement taken
out by the party indicated below (Principal to tick the appropriate box):

 Department of Education  Non-Government school  Employer

NOTE: PUBLIC LIABILITY INSURANCE

Public liability insurance of at least $10 million cover per event must be held or taken out, prior to the Student commencing Work
Experience under the Arrangement:
i. when an Arrangement is entered into by a Principal of a Government School in respect of a Government School student, by
the Department of Education with the insured being the Student and the Employer.
ii. when an Arrangement is entered into by a Principal of a Non-Government School in respect of a Non-Government School
student – either:
a. by that School, with the insured being the School and the Student; or
b. by the Employer, with the insured being the Employer and the Student, if the Principal of that School has advised the
Employer at least four (4) weeks prior to the Student commencing work experience that the School does not have public
liability insurance as set out above.
PRINCIPAL CONSENT
Dr Paul Shannon
I,____________________________________________ Mazenod College
Principal of ______________________________________________
enter into an Arrangement for the above named Student of this school to be engaged for the purpose of Work Experience by the
Employer named above in accordance with the provisions of the Education and Training Reform Act 2006 and Ministerial Order
1413 – Work Experience Arrangements, and on the basis of the information provided above and the Employer’s
acknowledgements. I confirm that I have informed the Employer as to whether this school holds public liability insurance. I will
ensure that the above named Student will complete the occupational health and safety program as required by the Department
of Education prior to commencing the placement under this Arrangement. I confirm that if the Student, or if the Student is under
18 years of age, the Parent/Guardian of the Student, has provided their consent, any necessary health information in relation to
the Student of which I am aware and may disclose pursuant to the Health Records Act 2001 will be released by me to the
Employer.

Principal’s signature Date / /

 Work Experience Travel and
Accommodation Form
Education and Training Reform Act 2006 – Ministerial
Order 1413: Work Experience Arrangements (Schools)

STUDENT DETAILS
Surname First Name Birth Date / /
School Name and Address Mazenod College, Kernot Avenue, MULGRAVE 3170 VIC
MULGRAVE VIC Postcode 3170 Telephone Vivian Seremetis (03) 9560 0911
Work Experience Coordinator Vivian Seremetis Student Year Level

IN CASE OF AN EMERGENCY, THE EMPLOYER SHOULD CONTACT THE STUDENT’S PARENT OR GUARDIAN AND
THE WORK EXPERIENCE COORDINATOR:
Name (Parent/Guardian)
Address Postcode
Tel. (Home) (Work) (Mobile)
Emergency contact (Name and Tel.)
PRIVACY INFORMATION: The information provided on this form is for the administration of Work Experience
Arrangements only and is not to be used for any other purpose. This information must be kept confidential.
WORK PLACEMENT DETAILS
Employer (business) name Tel.
Business address Postcode
Employer email address _____________________________________________________________________
Student’s work location address Postcode
Workplace contact person Supervisor
Work Experience hours am / pm, to am / pm; on  Monday  Tuesday  Wednesday  Thursday  Friday
from (commencement date) to (completion date) Total number of days
If insufficient space for dates and hours, please attach an additional sheet.
TRAVEL WITH EMPLOYER
The following sections are to be completed only if the Student is required to undertake vehicle travel with the Employer
and/or nominated Supervisor/s as part of this Arrangement.
EMPLOYER ACKNOWLEDGEMENT
I, _____________________________________________ [name of individual, or on behalf of the employer if employer is an
incorporated body] will ensure that, if the student is required to undertake travel:
• the driver has a current and valid Australian driver's licence relevant to the vehicle the driver uses;
• the driver is not disqualified or suspended from driving;
• the driver is not subject to any other impediments to their ability to drive a motor or other vehicle (as relevant);
• the vehicle in which the Student is to be transported is comprehensively insured; and
• to the best of my knowledge the vehicle in which the Student is to be transported is roadworthy, safe for normal road use and
suitable for the work-related purposes to which it will be put.

Signature Date / /

PARENT/GUARDIAN CONSENT (if Student is aged under 18 years)

I, ____________________________________________, consent to my child undertaking vehicle travel with the Employer

and/or nominated Supervisor/s as part of this Arrangement.

Signature  Parent or  Guardian Date / /

STUDENT CONSENT (if aged 18 years or over)

I, ____________________________________________, consent to undertaking vehicle travel with the Employer and/or

nominated Supervisor/s as part of this Arrangement.

Signature Date / /