239 White Road Wonthaggi Vic 3995
Before filling out this form, please ensure you have read and understood all information given to you regarding your training.
Please ensure you read and sign the declaration at the end of the form. If you have any questions, please contact the centre on or 56723115
Name of course
Course/Training Name:
How did you hear about this training?
❑ Brochure ❑ Local paper ❑ Friend/relative ❑ Website ❑Social media ❑ Agency ❑ Other ______
Personal Information
Family Name ______Former Surname______
Given Names ______Title______
Please give name accurately and legibly as they will be used on any certificates or results issued to you
Date of Birth (dd/mm/yyyy) ____/____/______Gender Male ❑ Female ❑
Residential Address
Street______
Town ______State ______Post code ______
Postal Address
❑ As above
OR PO Box or RMB Number ______
Town ______State ______Postcode ______
Contact details
Home phone ______Work phone ______
Mobile ______Email ______
Your Victorian Student Number
Do you have a Victorian Student Number (VSN)?
Yes ______Yes but unknown ❑ No never issued ❑ Don’t know ❑
Emergency Contact
Person ______Relationship to you______
Phone______Mobile ______
Citizenship & Language
Are you and Australian Citizen Yes ❑ No ❑
If NO which country were you born? ______
Do you speak a language other than English? Yes ❑ No ❑
If YES, which language? ______
If from non-English speaking background, how well do you speak English? Very well ❑ Well ❑ Not well ❑ Not at all ❑
If you are NOT a permanent resident or citizen of Australia
PLEASEBRING YOUR PASSPORT/LATEST VISA WHEN ENROLLING
Originating country (on passport) ______Date arrived in Australia ______
Passport No ______Visa No______
Visa subclass number/type ______Visa expiry date______
Cultural Background
Are you of Aboriginal or Torres Strait Islander origin? No ❑ Aboriginal ❑ Torres Strait Islander ❑ Both ❑
Secondary schooling
Are you still in secondary school? Yes ❑ No ❑
What is the highest level you SUCCESSFULLY COMPLETED in secondary school in Australia?
Year 12 ❑ Year 11 ❑ Year 10 ❑ Year 9❑ Year 8 or below ❑ Did not go to school ❑
When did you complete this level? ______Where? ______
Current employment status
Which best describes your current employment status?
▢Full time employee ▢ Unemployed – unpaid worker in a family business
▢Part-time employee ▢ Unemployed – seeking full-time work
▢Self-employed - not employing others ▢Unemployed – seeking part-time work
▢Employer – employing more than 1 staff ▢Not employed – not seeking employment
Further education history
Have you SUCCESSFULLY COMPLETED any of the following qualification in Australia?
▢ Bachelor degree or higher ▢ Advanced diploma or associate degree ▢ Diploma
▢ Certificate IV ▢ Certificate III▢ Certificate II
▢ Certificate I▢ Other▢ None
Do you have a disability?
Do you consider yourself to have a disability for which you may require assistance? No ❑ Yes ❑ (please specify)
▢Hearing ▢ Vision ▢Intellectual ▢ Learning ▢Mental illness ▢ Acquired Brain Injury (ABI)
▢ Physical ▢ Medical Condition ▢ Other ______
Do you have a medical condition we may need to know about?
Do you have any pre-existing ailments (requiring possible treatment) that we need to know about: Yes No
If yes, please give following details
Doctor/hospital if required ______Tel No ______
Ambulance subscriber Yes No Health Fund ______
Medication to be kept at Centre Yes No Type ______
Have you briefed staff on required emergency actions to be taken? Yes No
Reason for study
▢ To get a job ▢To get a better job or promotion ▢ For personal interest/self-development
▢ To develop my existing business ▢ It was a requirement of my job▢Other reasons
▢To start my own business ▢ I wanted extra skills for my job
▢To try for a different career ▢To get into another course of study
Do you have a CENTRELINK concession?
Do you have a Centrelink concession card? ▢ No ▢ Yes (please show at enrolment)
If yes, complete the following
Type ______CRN number ______Expiry date ______
Other Government training
Are you enrolled in any other accredited Government funded training? ▢ Yes ▢ No
If yes – give summary ______
Are you enrolled in the Skills for Education and Employment (SEE) program? ▢ Yes ▢ No
Do you wish to apply for Credit Transfer (CT) or Recognition of Prior Learning (RPL)?
Are you applying for CT or RPL against any of this training (if relevant)?
▢ Yes ▢ No ▢ Not sure (please ask your enrolling officer about this if unsure)
Impact on future training
Upon successful completion of a course or qualification that is government funded, you will not be able to obtain government subsidies for any course at the same level of your current qualification, even if it is in a different field of study.
Also you may only undertake 2 government funded courses in a given year.
Do you understand this statement? ▢ Yes ▢ No
Permissions
Do you give permission for
Your work to be placed on view in the centre (if relevant) ▢ Yes ▢ No
Your image to appear in our publicity – brochure, local print media, centre handbooks ▢ Yes ▢ No
Course fees
Name of course ______
Date of enrolment ______
Type of training(leave blank if unsure)
❑ Accredited course ❑ Training Package ❑ Accredited Unit ❑ Pre-accredited course ❑ Other
Level ❑ Preliminary/initial ❑ I ❑ II ❑ III ❑ IV ❑ Not applicable ❑ unsure
Fees estimate(leave blank if unsure)
Student tuition contribution $ ______
Amenities fee$ ______
Materials fee$ ______
Other fee$ ______(Description of fee ______)
Total Fee Payable $
Credit Card Payments
Card type ▢ VISA ▢ MasterCard (sorry we do not take AMEX)
Card Number ______
Card Expiry date (mm/yy) ______/ ______
Card Holders Name ______
Card Holders Signature ______
Is an agency paying for your course
▢ No ▢ Yes
Declaration
I understand that Bass Coast Adult Education Centre is required to provide the Victorian Government (HEGS) with student and training activity data which may include information I provide in this enrolment form. Information is required to be provided in accordance with the Victorian VET student statistical collection guidelines (which are available at gov.au/corporate/ statistics/submit_data). HESG may use the information provided to it for planning, administration, policy development, program evaluation, resource allocation, reporting and/or research activities. For these and other lawful purposes, HESG may also disclose information to its consultants, advisers, other government agencies, professional bodies and or other organisations.
I attest that I am NOT enrolled in the Commonwealth Government’s Skills for Education and Employment program, and that I am not enrolled in more than 1 other accredited, funded course this year. I understand that enrolling in this course may affect my future training options and eligibility for further government subsidised training under the Victorian Training Guarantee.
The Education and Training Reform Act 2006 requires Bass Coast Adult Education Centre to collect and disclose my personal information for a number of purposes including the allocation to me of a Victorian Student Number and updating my personal information on the Victorian Student Register.
I have been given information upon enrolment, have read and understood it. Iagree to be bound by the centres’ policies and procedures and code of conduct whilst enrolled as a student here.
I agree to the release of my personal/medical information for educational reasons or to meet legal obligations or in the case of an emergency, as authorised in accordance with privacy policies and legislation.
I have been made aware of, read, understood and agree with all fees and charges applying to this course prior to signing this form. This information includes course cancellations and refunds.
I understand that should I need to travel in any staff member’s vehicle that staff members and/or this centre will take every care but no responsibility during travel times.
I agree that I am entitled to a Statement of Attainment at no extra cost, for each unit completed and fully paid for. However reprints of certificates and Statements of Attainment will incur a fee.
I acknowledge and agree with the terms described above and those set out in all Student information given to me. I agree with the Individual Training Plan that has been created by the Centre staff for me. I understand that I can request information on this and request changes when and where I require it, and agree to make changes when required.
I acknowledge and agree to the terms, conditions and privacy statement above. I declare that the information provided on this enrolment form is, to the best of my knowledge true, correct and complete at the time of my enrolment. I acknowledge that any false information and/or failing to disclose any relevant information to my application for enrolment may result in the withdrawal of any enrolment, particularly as it relates to my eligibility to obtain an offer of government subsidised training and/or cancellation of enrolment at the discretion of the Bass Coast Adult Education centre.
Student Signature Date (dd/mm/yyyy) _____/ _____/ ______
Bass Coast Adult Education Enrolment Form 07/13 Page 1