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Enrolment Form

PERSONAL DETAILS

1.Title

Family Name

Given Name(s)

2.USI

3.Contact Number

4.Email

5.Date of Birth

6.Gender

7.Select a Residential Address

8.Select a Postal Address

LANGUAGE AND CULTURAL DIVERSITY

9. County of Birth

Australia

Other, please specify:

10. Residency

Australian Citizen

Permanent Resident

Temporary Resident

Visa Holder - please specify:

11. Do you speak a language other than English at home?

No, English only, (go to question 13)

Other, please specify:

12. How well do you speak English?

Very well

Well

Not well

Not at all

13. Are you of Aboriginal or Torres Strait Islander origin?

No

Yes, Aboriginal

Yes, Torres Strait Islander

DISABILITY

14. Do you have a disability, impairment, or long-term condition?

Yes

No, go to question 17

15. If YES, then please indicate the areas of disability, impairment, or long-term condition:

Hearing/Deaf

Mental Illness

Acquired Brain impairment

Medical Condition

Physical

Vision

Intellectual

Learning

Other:

ASSISTANCE

16. If you consider yourself to have a disability or impairment which may impact on your ability to complete this training, can you suggest ways the trainer can assist you?

17. What is your highest COMPLETED school level?

18. In which YEAR did you complete that school level?

19. Are you still attending secondary or senior secondary education?

Yes

No

PREVIOUS QUALIFICATIONS ACHIEVED

20. Have you SUCCESSFULLY completed any of the below qualificatons?

Yes

No, go to question 23

22. If YES, then tick ANY applicable boxes

Bachelor Degree or Higher 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

Other education (including certificates not listed above)

EMPLOYMENT

23. Of the following categories, which BEST describes your current employment status?

REASON FOR STUDY

24. Of the following categories, which BEST describes your main reason for undertaking this course?

DECLARATION AND AGREEMENT

I declare that the information I have supplied on this form is true and correct.

I have read all policies and student information on the website: www.karensheldontraining.com.au, along with specific course information and accept the terms and conditions of enrolment and agree to abide by the code of conduct as set out by Karen Sheldon Training.Student Information

I also understand the information contained in this form may be provided to Government education and training departments to assist with research and future funding initiatives. I consent to this occurring and certify that all details provided in this form are correct.

I give permission for Karen Sheldon Training to search for my USI or if I do not have a USI, to apply on my behalf if appropriate identification has been supplied.

I give permission for Karen Sheldon Training to take photos, and use photos of me for Good News Stories, Newsletters, and other Marketing during our training course/s.

Yes

No

Student Name

Student Signature

Date

Thanks for submitting!

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(08) 7915 7001
info@karensheldontraining.com.au

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