High School Co-Operative Education Program

Worksite Placement - Application Form & Interview Questions


Applicant Information
Date: 2/10/2012
Name
Last Name:     First Name:     Middle Name:
Home Address
Street # and Name (include Apt. / Unit #):
City/Town/Village:     Province:     Postal Code:
Phone Number
Email Address
Linguistic Profile
English   French   Bilingual (first language English)   Bilingual (first language French)  
Name of School
Location (city/town/village)
Grade
Name of Coop Teacher
 
In Case Of Emergency Contact
Name & relationship
Phone Number
Home:
Work:
 
Worksite Placement Request
Healthcare Profession(s) of interest
How many weeks being requested?
Dates being requested
Time being requested
 
Interview Questions
1. In the application form, you have identified a healthcare profession(s) of interest. Explain why you are interested in this/these profession(s).
2. What have you already learned about this/these profession(s) and where/how did you acquire your knowledge.
3. What future educational plans do you have?

Have you applied to a post-secondary educational institution? Yes   No  
To which program of study have you applied? Have you been accepted? (answer if applicable)
4. What steps have you taken to put yourself in a position to be a valuable candidate for enrollment? For example, school courses, career exploration, volunteering, etc.
5. In addition to completing this on-line Worksite Placement Application Form - Interview Questions, you have been asked to read the Worksite Placement Information Sheet. Please summarize what you have learned - what is expected of you prior to your placement and during your placement.
6. What are your expectations in completing a worksite placement?
By checking this box, I acknowledge that I have read the Worksite Placement Information Sheet and I agree to adhere to the policies and procedures detailed within. If granted a worksite placement, I will provide on the first day the Proof of Satisfactory Medical Examination and complete a Confidentiality Declaration of Understanding. I will upon conclusion of my worksite placement complete and submit the Post Placement Evaluation Form and return the identification badge that was provided to me for the duration of my placement only.
By checking this box, I authorize the Education Liaison to communicate with me in the future via the permanent address that I have provided through my worksite placement application. I understand that the RHA wishes to evaluate the impact of my worksite placement with the Regional Health Authority as a determinant in my post secondary destination and/or career choice.