v. 11-12-2014

Section 1: CHCCS413B Support Individuals with Autism Spectrum Disorder

Name (This is what will appear on your qualification) / Date of course / Click to add date /
Title / Choose / Surname
Given Names
Residential Address
Street Address
Suburb / State / Post Code
Postal Address (If different from above)
Postal Address
Suburb / State / Post Code
Personal Details
Company
Occupation / Highest level of Education / Choose Year completed
Position / role
Of the following categories, which BEST describes your current employment status? / Choose /
Do you consider yourself to have a disability, impairment, long term condition or current work cover claim? / Choose Comment:
Phone (w)
Phone (h) / Fax
Mobile / Email
Date of Birth / Click to add date / Country of Birth / Gender / Choose /
Do you speak a language other than English at home? If Yes, please specify.
What is your proficiency in English? / Choose
Choose / Are you of Aboriginal or Torres Strait Islander origin? / Choose / What is your main study reason / Choose
Emergency Contact
Person: Relationship: Phone: Mobile:
Literacy Assessment. To ensure you meet the literacy requirements for this course, please answer the following two questions. Please use complete sentences and write no less than 50 words for each answer.
Q1 / What does the term ‘Autism Spectrum Disorder’ mean to you?
Q2 / What is your current knowledge of the Disability Act 2006 and how does it impact on the work you do?
Course Details
Course Name
Course Date / Course Location
Further Information
By answering the following questions, you will help us ensure the training meets the needs of our participants
How did you hear about this course?
What expectations do you have for this training?
What experience do you have supporting individuals with Autism Spectrum Disorder? (this is not a requirement to attend the course)
How do you feel you will use this qualification once you complete it?
Do you have any specific needs or requirements not already mentioned that we should be aware of? Please include any dietary requirements.

Section 2:

Applicant Declaration

Applicant Declaration (This section must be completed. If left blank the enrolment will not be accepted)
Before signing this enrolment form, please ensure you have read and/or understand the following information. Please put a tick next to each one:
All contents of the Student Handbook
The Cancellation Policy
The Plagiarism Policy
Pla / I have read the following information



I understand that all fees must be paid prior to the commencement of the course / Click /
OTHER RELEVANT INFORMATION:
Access & Equity policy:
Autism Victoria adheres to an access and equity policy for the provision of all of its services. This document is available on request.
Privacy of Information:
Information provided to students will be covered by the Privacy of Information Act. Such information will not be released to a third party without the written permission of the students. Students may access their own records on providing proof of identity to the Manager.
NOTE: If you are emailing this enrolment form, and therefore unable to provide an original signature then you must state the following inside your email. “I [your full name], agree to the applicant declaration as stated on the Autism Victoria application for on [today’s date].” / I have read the following information


Name: / Signature: / Date: / Click here /
PLEASE NOTE: By completing all areas of this application form, you will assist us to customise the course to better meet your needs. We ask that you take the time to complete all questions. Please note that minimum language, literacy, and numeracy standards are required to enrol for the course. If you have difficulties completing theses questions, please contact us for a confidential interview to discuss your suitability for the course.
We also assume a minimum understanding of using computers, including using word processing applications such as Microsoft Word to type, set up tables and print; using email to communicate with your trainer; and using the Internet to search and locate information. If you believe that your computer skills may not meet the required minimum standard expected of students, please call us for a discussion.
Once you have completed this five page application form, please scan and email, post or fax to the contact details below. We will contact you via phone or email to confirm enrolment. Please note a phone or face to face discussion may be required to ensure that this course is suitable for you and that we are able to provide appropriate support for you, if required.

Section 3: Payment Details (Payment is required at time of enrolment)

Please fill this in so an invoice can be raised to ‘you’
Learner Name
Cost of Course
Postal Address
Suburb / State / Postcode
Please fill in below if the invoice is going to a ‘company or your employer’
Learner name
Cost of Course
Company name
Postal Address
Suburb / State / Postcode
Owner / Manager
Phone (w) / Fax
Email
Payment options
Direct Deposit
A/C Name: Autism Victoria
BSB: 063 113 A/C: 00904093
Please quote your full name as this will help us allocate your payment correctly / Bank or personal cheque
Money order
Made payable to: Autism Victoria
Payment Amount$
Credit card authorisation form
Cardholders name
I authorise Autism Victoria to debit from my card the amount of $
Card number
Expiry Date / Type of card
Signature
Would you like a tax invoice sent to you?
Autism Victoria use only
Payment received / / Invoice Number
Invoice Amount
Course Date & Venue / Course Name
RPL or (RCC) / RPL or (RCC) information attached
Application Declaration has been:
a)filled in signed and dated by applicant
b)emailed by applicant with above mentioned statement.
/ Comments:
Admin Comments:

Amaze Knowledge, 24 Drummond Street, Carlton South 3053. Po Box 374

Ph 1300 262 935. Fax (03) 9639 4955.