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Cert IV - Disability
Cert IV in Disability Enquiry
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CHC40312 - Certificate IV in Disability
PARTICIPANT ENROLMENT FORM -
THIS INFORMATION IS STRICTLY CONFIDENTIAL
Course Start Date
*
August 2014
VENUE:
Unit 5 / 675 Boronia Road,
Wantirna Vic 3152
TIME:
To be confirmed
What name do you want displayed on your Certificate
(please check spelling)
First, Last Name
*
Title
*
Preferred Name
*
Postal / Street Address
*
Postal / Street Address 2
*
Suburb
*
State
*
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
*
Phone:
*
Mobile:
*
Email
*
Date of Birth:
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
Gender
*
Male
Female
Emergency Contact Person:
*
First
Last
Emergency Phone:
*
Relationship
*
Are you new to the Victorian Education system or do not have your Victorian Student Number?
*
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:
*
In which country were you born?
*
Do you speak a language other than English at home?
*
Yes
No
If yes, please specify:
*
How well do you speak English?
*
Very Well
Well
Not Well
Are you of Aboriginal or Torres Strait Islander origin?
*
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.
*
Yes
No
Please tick if any of these areas relate to you:
*
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:
*
Education History
What is your highest completed school level?
*
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?
*
Have you successfully completed any of the below qualifications?
*
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
*
2. Course Name
*
3. Course Name
*
Institution
*
Institution
*
Institution
*
Duration
*
Duration
*
Duration
*
Year
*
Year
*
Year
*
Completed
*
Completed
*
Completed
*
Employment History
Of the following, which BEST describes your current employment status?
*
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
*
Employer
*
Employer
*
Position
*
Position
*
Position
*
Commenced
*
Commenced
*
Commenced
*
Completed
*
Completed
*
Completed
*
Of the following categories, which BEST describes your main reason for undertaking this course / training?
*
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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