INFORMATION REQUIRED FOR SCHOOL EXPERIENCE

This information is essential for us to administer placements. Whilst we will do our best to respond to your personal circumstances, the placement of students is a complex exercise involving a range of variables. Our overall concern is to maximise professional competence. Please ensure you complete all sections.

Course:

Surname: / Title:
Forename: / Middle Name:
Date of Birth:
/ / Email Address: /
Term-time Address:
(please write “Halls” if you intend to live on Campus)
Post Code:
Mobile:
Home Address:
(if different to term-time address)
Emergency Contact Name & Telephone Number:
Telephone:

Please list below any schools within a 50 mile radius of Northampton (or your home address if you intend to live at home) with which you have connections through previous experience (i.e. family or friends teaching there or your own children attend).

Name of School/Setting / Location (i.e. Npton, Leics etc.) / Connection

TRANSPORT DETAILS

The University of Northampton works with schools and settings which may be a considerable distance from your home. This is important to ensure you have a wide range of experiences throughout the course. Please could you therefore supply the following information to help us with offering you suitable placements.

Do you hold a current driving licence? /
If “Yes”, when did you pass your test? / ______
Do you have your own transport available for placement journeys? /
If “Yes”, please specify the vehicle, i.e. car/motorbike. / ______
Are you willing to pick up other students?
(Please ensure your insurance covers this) /
Are you willing to drive a hire car?
(You may be required to pick up other students if you drive a hire car) /

Please include any other information and/or personal details you would like us to try and take into account when planning placements such as childcare issues etc. If you have declared a SEND that may affect your placement, please also include brief information below:

Signed: / Date:

Please return to:

Placements & Workbased Learning, Student Centre (SC205), The University of Northampton, Boughton Green Road, Northampton, NN2 7AL,

To return by email, please send to

If you have any queries regarding this form please call 01604 893781.