STUDENT ENROLMENT FORM
Company Name:
*
STUDENT INFORMATION
(As shown on identification)
Name
*
First Name
Last Name
DOB:
-
Day
-
Month
Year
Date
Mobile:
Home Phone:
Email:
*
Home Address:
Suburb:
Post Code:
Postal Address:
Gender
Male
Female
Non-binary
Prefer not to say
PLACE OF BIRTH / CITIZENSHIP DETAILS
Country of birth:
City of birth:
Country of Citizenship:
EMPLOYMENT STATUS
Australian Citizen/Passport Holder
Permanent Resident
New Zealand Citizen/Passport Holder
Other
Do you identify as:
Aboriginal
Torres Straight Islander
Neither
Please select from below
Full Time Empolyee
Part Time Employee
Casual Employee
Self Employed -Employing others
Self Employed - Not employing others
Employed - Unpaid in a family business
Employed - Seeking full time work
Unemployed - Seeking part time work
LANGUAGE / SCHOOLING
Do you speak a language other than English at home:
Yes
No
If Yes, what language do you speak:
How well do you speak English?
Very well
Well
Not well
Not at all
Are you attending School
Yes
No
If Yes, what is the name of the school:
Highest Level Completed
Year 12
Year 11
Year 10
Year 9 or equivalent
Year 8 or below
Never attended
What year did you complete school:
Are you currently enrolled in any studies
Yes
No
ADDITIONAL SUPPORT REQUIRED
Do you need assistance with Reading, Writing or Math?
Yes
No
Not Sure
Do you consider yourself to have a disability, impairment or long term health condition?
Yes
No
Rather not say
If you answered YES to the above question, please indicate below what you may require further assistance with:
Hearing Deaf
Mental Illness
Physical
Acquired brain impairment
Intellectual
Vision
Learning
Medical condition
Other
PREVIOUS EDUCATION
If you have previously completed any other qualifications, please complete the table below:
Please choose one from below
Certificate I
Certificate II
Certificate III
Diploma
Adv. Diploma
Bachelor Degree
Other
PARTICIPANT IDENTIFIER
Unique Student Identifier (USI) Number:
EMERGENCY CONTACT DETAILS
Name
Given Name
Last Name
Relationship to you
Contact Number
QUALIFICATION INFORMATION
Please select 1 qualification from below
Please Select
Advanced Diploma of Surface Coal Mining Management
Certificate III in Civil Construction
Certificate III in Process Plant Operations
Certificate III in Surface Extraction Operation
Certificate IV in Building and Construction
Certificate IV in Civil Construction
Certificate IV in Engineering
Certificate IV in Surface Coal Mining (Open Cut Examiner)
Diploma of Surface Operations Management
Qld Coal Mining - Standard 22 Units
STUDENT DECLARATION
Please tick appropriate boxes below.
I consent to the collection, use and disclosure of my personal information to any government body required to undertake training. I certify that the information on this form is correct and true to the best of my ability.
I give permission to the nominated supervising RTO to take and use my photographs and or digital/images in social media and marketing campaigns as appropriate.
Students Signature
Date
-
Day
-
Month
Year
Date
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