(Please enter your name as you would like it to appear on your qualifications)
EMPLOYMENT DETAILS / Employer: ______
Address: ______
______ Post Code: ______
Phone Number (Wk): ______Fax Number (Wk): ______
Email: ______
PERSONAL
DETAILS / Preferred Title: (tick) Mr Mrs Ms Miss Other ______
Date of Birth: ____/____/____ (dd/mm/yyyy) Gender: (tick) Male Female
Phone Number (Hm): ______Phone Number (Mbl): ______
Email: ______
ADDRESS
DETAILS / Residential Address: ______
______ Post Code:______
Postal Address: ______
______ Post Code:______
AVETMISS
DETAILS / Employment: (tick) Full Time Part Time Self Employed Employer Unemployed
Indigenous Status: (tick) Aboriginal Torres Strait Islander None
Country of Birth: (if not Australia) ______
Language Spoken at Home: (if not English) ______
Do you have any condition that may effect your ability to learn? (tick) Yes No
If yes, please list: ______
Do you have any reading/writing/language difficulties? (tick) Yes No
If yes, please list: ______
School Level: (tick) Year 8 or below Year 9 Year 10 Year 11 Year 12
Tertiary/Vocational Level: (tick) Cert I Cert II Cert III Cert IV Diploma
Advanced Diploma/Associate Degree Bachelor Degree/Higher Degree
Details: ______
QUALIFICATION /COURSE ENROLMENT DETAILS
DATE OF COURSE: / ___/___/______(Please identify the course or unit of competency you wish to enrol in at this time)
EMERGENCY MANAGEMENT COURSES / IEM / Introduction to Emergency ManagementIEM-LG / Introduction to Emergency Management for Local Government
IERM / Introduction to Emergency Risk Management
TASSES COURSES / Basic Roping
Four Wheel Drive Operations
Traffic Control
ATV Operators
PUBLIC SAFETY TRAINING PACKAGE UNITS OF COMPETENCY
Communicate in the workplace
Provide services to clients
Follow defined OH&S policies and procedures
Work in a team
Work effectively in a public safety organisation
Provide basic emergency life support
Apply first aid
Participate in a rescue operation
Prepare, maintain and test response equipment
Maintain safety at an incident scene
Operate communications systems and equipment
Drive operational vehicles
Protect and preserve incident scene
Trim and cut felled trees
Participate in an urban search and rescue Category 1
Navigate to an incident
Interpret road maps and navigate pre-determined routes
Search as a member of a land search team
Work in an aviation environment
Search as a member of an air search team
Undertake road crash rescue
Undertake vertical rescue
Undertake storm water damage operations
Undertake storm water damage operations performed at heights
Work as a team member in an emergency operations centre
Control a Level 1 incident
Conduct briefings and debriefings
INFORMATION ACCESS / If you are being sponsored by a third party, such as your employer, do you give permission for information about your progress in the qualification to be given to this person/organization, if requested? (tick) Yes No
DECLARATION / I declare that the information I have provided in this enrolment is true and correct.
Signature: ______ Date: ____/____/____
PERSONAL INFORMATION PROTECTION
Personal information will be collected from you for the purpose of training provision by the Tasmania State Emergency Service. Failure to provide all the information may result in your registration not being processed. Your personal information will be used for the primary purpose for which it is collected. Your basic personal information may be disclosed to other public sector bodies where necessary for the efficient storage and use of the information. Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to the Tasmania State Emergency Service You may be charged a fee for this service.
Course Enrolment Form (Non SES) Version 2.3 (January 2014)