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Cert IV - Disability
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CHC40312 - Certificate IV in Disability
PARTICIPANT ENROLMENT FORM -
THIS INFORMATION IS STRICTLY CONFIDENTIAL
*
Indicates required field
Course Start Date
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August 2014
VENUE:
677 Boronia Road,
Wantirna Vic 3152
TIME:
To be confirmed
What name do you want displayed on your Certificate
(please check spelling)
First, Last Name
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Title
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Preferred Name
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Postal / Street Address
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Postal / Street Address 2
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Suburb
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State
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VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
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Phone:
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Mobile:
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Email
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Date of Birth:
Day
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1
2
3
4
5
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7
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Month
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January
February
March
April
May
June
July
August
September
October
November
December
Year
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Gender
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Male
Female
Emergency Contact Person:
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First
Last
Emergency Phone:
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Relationship
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Are you new to the Victorian Education system or do not have your Victorian Student Number?
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YES, I am new to the Victorian Education System, I have never attended a Victorian school, TAFE or other training provider
NO, I have forgotten my Victorian Student Number
If you answered Yes to the above, or are aged 24 or below at the time of enrolment, please provide your Victorian Student Number:
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In which country were you born?
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Do you speak a language other than English at home?
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Yes
No
If yes, please specify:
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How well do you speak English?
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Very Well
Well
Not Well
Are you of Aboriginal or Torres Strait Islander origin?
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Yes - Aboriginal
Yes - Torres Strait Islander
No
Do you have a disability / impairment / religion / culture – that would affect the way the trainer delivers the course? If yes, please speak with your trainer and specify any helpful information below.
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Yes
No
Please tick if any of these areas relate to you:
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Hearing/Deaf
Vision
Physical
Intellectual
Illness
Religion
Cultural
Other Condition/Situation
Please specify any information that can assist us in the delivery of the course:
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Education History
What is your highest completed school level?
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YEAR 12 or equivalent
YEAR 11 or equivalent
YEAR 10 or equivalent
YEAR 9 or equivalent
YEAR 8 or below
Never attended school
Still attending school
In which year did you complete your last year of school?
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Have you successfully completed any of the below qualifications?
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Bachelor Degree or Higher
Advanced Diploma or Associate Degree
Diploma or Associate Diploma
Certificate IV
Certificate III
Certificate II
Certificate I
None of the above
1. Course Name
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2. Course Name
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3. Course Name
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Institution
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Institution
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Institution
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Duration
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Duration
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Duration
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Year
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Year
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Year
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Completed
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Completed
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Completed
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Employment History
Of the following, which BEST describes your current employment status?
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Full-time employee
Part-time employee
Self employed not employing others
Employer
Employed - Unpaid worker in a family business
Unemployed - Seeking full-time work
Unemployed - Seeking part-time work
Not employed - Not seeking employment
Employer
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Employer
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Employer
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Position
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Position
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Position
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Commenced
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Commenced
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Commenced
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Completed
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Completed
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Completed
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Of the following categories, which BEST describes your main reason for undertaking this course / training?
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To get a job
To develop my existing business
To start my own business
To try a different career
To get a better job / promotion
It was a requirement of my job
I wanted extra skills for my job
To get into another course of study
For personal interest or self-development
Other reasons
Please indicate how you found out about our course:
*
Website / Google
Facebook
Flyer / Advertising
Word of Mouth
Other
Would you like to be reminded about course updates in the future?
*
Yes
No
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