Student Enrolment Form

STUDENT ENROLMENT FORM

Student Details

Title:

First Name:

Middle Name(s):

Last Name:

Date of Birth:

Gender:

Work Phone:

Mobile Phone:

Email:

Emergency Contact

Full Name:

Phone:

Mobile Phone:

Home Address/Mailing Address

Address 1:

Address 2:

City/Suburb:

State:

Post Code:

Current Employer Details

Business Name:

Contact:

Phone:

Email:

Address 1:

Address 2:

City/Suburb:

State:

Post Code:

1. Employment Details
Which of the following categories best describes your current employment status?
Select One

2. Home Language
Do you speak a language other than English at home?
Select One

No English only
Yes Other (Please Specify)

3. How well do you speak english?
Select One

Very well
Well
Not well
Not at all

4.How well do you write English?
Select One

Very well
Well
Not well
Not at all

5. Do you identify with Aboriginal or Torres Strait Islander Origin?
Select One

No
Yes - Aboriginal
Yes - Torres Straight Islander
Yes - Aboriginal & Torres Straight Islander

6. Secondary Education
What is your highest completed secondary school level?
Select One

Completed Year 9 or lower
Completed Year 10
Completed Year 11
Completed Year 12

In which year did you complete that school level?

7. Special Needs
Do you consider yourself to have a disability, impairment or long term condition?
Select One

Yes
No

If yes, then please indicate the areas of disability, impairment or long term condition.
Select One or More

Hearing/Deaf

Physical

Intellectual

Learning

Mental Illness

Acquired Brain Impairment

Vision

Medical

Other (Specify Below)

8. If you answered YES to the above question, will you need any special assistance, because of the disability?
Select One or More

Equipment

Physical Access

An interpreter (sign)

A Note Taker

Taped Materials

Large Print Materials

Other (Specify Below)

9. Post Secondary Education
Have you successfully completed any of the following qualifications?

Yes
No

If yes, tick any applicable boxes.

Bachelor Degree

Advanced Diploma (or Associate Degree)

Diploma (or Associate Diploma)

Certificate IV (or Advanced Certificate/Technician)

Certificate III (or Trade Certificate)

Certificate II

Certificate I

Certificates other than above

10. Declaration
I accept responsibility for the accuracy of my enrolment record.
I also acknowledge that, I am subject to the statutes, regulations and rules of the AQTF Training Guidelines.

Yes
No

I give permission for my results to be released to employers or other authorised persons.

Yes
No

I give permission to Intertag Pty Ltd to use my course photograph and/or testimonial for marketing purposes.

Yes
No