www.hcpc-uk.org To request this document in Welsh or an alternative format, email publications@hcpc-uk.org Crystal Mark 18760 Clarity approved by Plain English Campaign © Health and Care Professions Council 2016 Publication code 20091211gPOLPUB (amended June 2016) This publication is produced using trees from sustainable forests and recycled fibre. Appendix 5 - Student Placement Profile Application Form Student Details Name of Student: Email: Term Time Address Home Address Telephone: Gender: (please include mobile) University DBS Date DBS was completed: Reference number: DBS You are expected to take your copy of your DBS to interviews with an agency. If you no longer have your DBS please contact your placement tutor Placement Tutor: Gert Scheepers Placement Level: Year of entry into the programme? Length of Placement: Is this a repeat placement? Part-time student? Are you sponsored by Name of employer sponsor: your employer? Valid driving licence Own car/motorbike to use to and from placement, and whilst on placement? I confirm that the Do you have access to a vehicle I use for bicycle and are you able to placement travel has use it to travel during your
www.hcpc-uk.org To request this document in Welsh or an alternative format, email publications@hcpc-uk.org Crystal Mark 18760 Clarity approved by Plain English Campaign © Health and Care Professions Council 2016 Publication code 20091211gPOLPUB (amended June 2016) This publication is produced using trees from sustainable forests and recycled fibre. Appendix 5 - Student Placement Profile Application Form Student Details Name of Student: Email: Term Time Address Home Address Telephone: (please include mobile) Gender: University DBS Reference number: Date DBS was completed: DBS You are expected to take your copy of your DBS to interviews with an agency. If you no longer have your DBS please contact your placement tutor Placement Tutor: Gert Scheepers Placement Level: Year of entry into the programme? Length of Placement: Is this a repeat placement? Part-time student? Are you sponsored by your employer? Name of employer sponsor: Valid driving licence Own car/motorbike to use to and from placement, and whilst on placement? I confirm that the vehicle I use for placement travel has Do you have access to a bicycle and are you able to use it to travel during your
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