Registration Form

Registration Form

Submission of this form does not guarantee enrolment, places will be confirmed via email.
Name of Course:*
Invoice to:*

StudentThird Party **If Third Party, please contact the Office for a Third Party Invoice Agreement form**
Your details
Full Name*
Gender*
Date of Birth*
Telephone - work
Telephone - home
Mobile*
Email address
Your usual address*

Unit/number/street

Suburb, locality or town

State/TerritoryPostcode
Do you have a PO Box?*

YesNo
Please complete PO Box details*

PO Box or roadside delivery box

Suburb, locality or town

State/TerritoryPostcode
For the purposes of Emergency Medical attention, do you have any allergies or additional information which may be relevant?*

NoYes
If yes, please provide more details:*
Emergency contact details
Emergency contact person (1)*
Relationship to you *
Phone no*
Emergency contact person (2)*
Relationship to you *
Phone no*
Do you have a disability, impairment or long-term condition?*

NoYes
If yes, please provide more details:*

Acquired Brain ImpairmentHearing/DeafIntellectualLearningMedical ConditionMental IllnessOtherPhysicalVision
Do you require a carer to attend with you?*

NoYes
Do you have a current concession card?*
CRN Expiry Date*
How did you find out about the program?*
Membership - If you would like to become a member of Yarrunga Community Centre Inc*

NoYes (If yes, please ask at Reception)
Mailing List

You will automatically be added to our mailing list to receive news and updates from Yarrunga Community Centre, however you have the option to unsubscribe at any time.
Terms and Conditions
Payment and Refund Policy
Fees for courses are to be paid before the course commencement unless prior arrangements have been made.

If you withdraw one week or more prior to the course start date in writing, you will receive a full refund of the fees, less a $10 administration fee. If less than one week’s notice is given, 50% of the fee will be refunded less the $10 administration fee.

If we cancel a course for any reason, your fees will be refunded in full.

No refund will be issued once a course has commenced and you will still be liable for any unpaid fees.

For further information, please see Fees Information booklet.
Signature and Declaration (please read, you will be required to tick all the boxes before proceeding)*

If there is an emergency I allow those in charge to make decisions for my safety or well-being, including ambulance travel, medical treatment and hospitalisation.I understand that I have to pay for all my own medical bills and expenses.I understand that Yarrunga Community Centre Inc. will let me know about any planned excursions.
I will allow photographs/videos of me to be taken as part of my classes at Yarrunga Community Centre Inc. to be used on display boards, TV screens, web pages or CD’s, brochures/posters, video/audio, newsletters, newspaper articles or Annual reports.*

Yes, I doNo, I do not
Privacy Statement
Yarrunga Community Centre Inc. will not give any personal information about you to anyone else without your written permission. This is the law known as the Privacy Act, (2001).

For more information in relation to how student information may be used or disclosed please contact Yarrunga Community Centre's Privacy Officer on phone (03) 9722 8942 or email info@yarrunga.org.au.
Please read, you will be required to tick all the boxes before proceeding.*

I acknowledge and agree to the Terms and Conditions for Payment and Refund Policy.I acknowledge that I have read the Privacy Statement.I hereby declare that the information provided in this application for enrolment is complete and accurate.By enrolling and signing the form you agree to abide by The Code of Conduct
Applicant under 18 years? Parent/Guardian to complete full name and sign the application form.
Full Name
Signature*

Clear
Sign using
Signature*

Clear
Sign using a mouse or if on an iPad/phone use your finger
Today's Date*
Please note: Students under 18 must attend with an adult
Should be Empty:

Registration Form

Your details

Emergency contact details

Terms and Conditions

Privacy Statement