Course Registration Form

Placement Questionairre

Your wild work placement adventure starts here.
Name*

First NameLast Name
Birth Date*

DayMonthYear
Mobile Number*
Please enter a valid phone number.
Email Address*
example@example.com
Residential Address*

Street Address

Street Address Line 2

CityState / Territory

Postal / Zip Code
Type of Placement Requested*
Course Studying*
University / TAFE*

Name of InstitutionLocation
Please Specify*
High School*

Name of High School / InstitutionLocation
Does your Institution / Course Provider provide workplace insurance coverage?*

YesNoUnsure
Duration of your placement?*

One Block Week (Mon - Fri)Routine Regular Placement
Preferred Start Date of Placement*

DayMonthYear
Select first day of placement
How many days a week?*

One DayTwo DaysThree Days
How long is your placement?*

3 months6 months12 months18 months
Weekday Availability (all shifts are 0800 - 1700)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
List any previous experience or completed qualifications working with animals:
Any additional comments or things that we should know:
Should be Empty:

Placement Questionairre