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	Tertiary Practicum Student Application Form		eCPC Home
Welcome Guest			26-Apr-2024 19:12

Declaration for Child Related Work - Tertiary Practicum Students

This declaration must be completed by students undertaking unpaid tertiary practicum placement with the Department of Education (the Department) where the person is required to hold a NSW Working with Children Check clearance under the Child Protection (Working with Children) Regulation 2013. See the Department's Working with Children Check Procedure for more details.

Name Details

Name on NSW WWCC clearance

Name Type

Title

First Name

Middle Name

Family Name

Are/were you known under a different name?*

Yes

No

Please select the name that was used on your NSW WWCC Clearance from the above

Street address:*

Street address (2):

Suburb:*

State:

Post Code:

Personal Email:*

Telephone:

Mobile:

Date of birth:*

Gender :*

Suburb/Town/City of birth:*

State of birth(if AUS):

Country of birth:*

Country of citizenship:*

NSW WWCC number from OCG (e.g. WWC1234567V):*

Departmental ID number (if known):

NSW Department of Education placement details (if known)

School

Anticipated start date of practicum placement:*

I give approval for my contact details to be included on relevant Department mailing lists. *

Yes

No

Identity document: Upload Government-issued photo identity document with full name, date of birth and current residential address and, if relevant, change of name document. The Department may verify any document with the issuing authority. Click here for guide to Identity Documents

Note:

A digital driver's licence's is not acceptable for Working With Children Check verification purposes. Digital IDs are only acceptable for club entries or if you are presenting yourself in person for identity verification.
Uploading documents is a two-step process 1. Click on the 'Choose' button to select your document from a directory 2. Click on 'Upload' to attach the chosen document to your application.
You will be required to provide more than one identity document if you don't have a single document that contains all the required information stated above.
The maximum size of any document to be uploaded cannot exceed 20mb.
Accepted file types - PNG, PDF, JPG, DOC and DOCX.

Choose/Upload proof of identity.

File Name
No records found.

Choose

Section A - I declare that:

I have no criminal convictions in the past ten years. I understand that "conviction" is defined in the Criminal Records Act 1991 and includes a conviction, whether summary or on indictment for an offence, and includes a finding or order that an offence has been proved, or that a person is guilty of an offence, without proceeding to conviction.
I am not subject to any pending court proceedings relating to a criminal matter in Australia or overseas.
I have no convictions that cannot become spent within the meaning of the Criminal Records Act 1991 including but not limited to:
1. convictions for which a prison sentence of more than six months has been imposed; or
2. convictions of sexual offences.

Section B – I am unable to make the relevant declaration in Section A.

Privacy Statement

The information collected on this declaration document and from identification documents you provide will be used by the Department to manage risk associated with its legal obligation to ensure the protection of children and young persons in its care, creating your department identity, email address and for purposes related to your engagement with the Department to enable you to complete your practicum.

The Department will use this information to verify your identity and NSW Working With Children Check (WWCC) clearance and to check the Department's business systems, to ensure that there is no barrier to engaging the person.

If you are cleared for engagement, this information will be entered onto the Department's database and you will be allocated a unique employee identification number and provided with an email address etc.

All information you provide will be used, disclosed and stored consistent with the NSW privacy and other relevant law. Identification documents are viewed to verify your identity and check details recorded on the declaration form. The completed declaration form and a record of the database check will be filed by the school/business area in secure storage for seven years from date of inactivity and then destroyed. You may request access to this information from the school or business centre at which it is held. The Department will not disclose the information to another agency or person unless required or authorised by law.

Failure to provide information required to complete this declaration and identity check may result in declination of your request to work as a volunteer or contractor.

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