School Based Application Form

School Based Application Form
Please fill out all applicable fields. Fields marked with (*) are mandatory.
Course Selection

Please note: If you are enrolling into CHC50121 - Diploma of Early Childhood Education and Care, a Statement of Attainment and transcript for Certificate III in Early Childhood Education and Care will need to be provided.
Please select your course*

CHC30121 - Certificate III in Early Childhood Education and CareCHC50121 - Diploma of Early Childhood Education and Care
Have successfully completed any units in the applicable course overview? If you have please supply a Statement of Attainment*

YesNo
Personal Details
Title*
Single Name only

(Tick this box if you have one name only that cannot be written in the following format. Write your single name in the 'Surname' section)
Full Name*

First Name(s)Middle NameLast Name
Full Name
Previous Surname/s
Gender*
Birth Date*

DayMonthYear
Current Age*
Contact Details
Email Address*
example@example.com
Alternative Email Address
example@example.com
Mobile Number*
Work Number
Emergency Contact
Emergency Contact Given Name*
Emergency Contact Last Name*
Emergency Contact Phone Number*
Emergency Contact Relation*
e.g. Mother/Father/Husband/Sister
Address*

Street Address

Street Address Line 2

CityState e.g. QLD

Post CodeCountry
Do you have a postal address different from the above?*

YesNo
Postal Address

Street Address

Street Address Line 2

CityState

Post Code
Postal PO Box
Language and Cultural Diversity
Citizenship Status*
Town/City of Birth*
Country of Birth*
Language Spoken*
Are you Aboriginal and/or Torres Strait Islander?*

NoYes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait Islander
How well do you speak English?*

Very wellWellNot wellNot at all
Do you speak a language other than English at home?*

No, English onlyYes
If yes, what language?
Disability
Do you consider that you have a disability, impairment or long-term condition?*

YesNo
Please specify:

Hearing/deafMental illnessPhysicalAcquired brain impairementIntellectualVisionLearningMedical conditionNeurological conditionOther
Schooling
Highest school level completed*

Never attended schoolYear 8 or belowYear 9 or equivalentYear 10 or equivalentYear 11 or equivalentYear 12 or equivalent
Are you currently still at school?*

YesNo
Name of Current School
Study Reason
Of the following categories, select the one which BEST describes the main reason you are undertaking this course/traineeship/apprenticeship*

To get a jobTo develop my existing businessTo start my own businessTo try for a different careerTo get a better job or promotionIt was a requirement of my jobI wanted extra skills for my jobTo get into another course of studyFor personal interest or self-developmentTo get skills for community/voluntary workOther reasons
Previous Qualifications Achieved
Have you successfully completed any qualifications?*

YesNo
Please Specify:

Bachelor degree or higher degreeAdvanced diploma or associate degreeDiploma (or associate diploma)Certificate IV (or advanced certificate/technician)Certificate III (or trade certificate)Certificate IICertificate IOther
Are you currently enrolled in another certificate course?*

YesNo
Please specify:
Employment Status
Of the following categories, which BEST describes your current employment status?*

Full-time employeePart-time employeeSelf employed - not employing othersSelf employed - employing othersEmployed - unpaid worker in a family businessUnemployed - seeking full-time workUnemployed - seeking part-time workNot employed - not seeking employment
Unique Student Identifier (USI)
Do you have a USI number?*

YesNo
Please provide your USI number
e.g. ABCD6EFG9H
If you do not have a USI number and you would like Imagine Education to apply for one on your behalf, you must authorise us to do so and declare that you have read the privacy information at https://www.usi.gov.au/documents/privacy-notice-when-rto-applies-their-behalf.

I authorise Imagine Education to apply, pursuant to sub-section 9(2) of the Student Identifiers Act 2014, for a USI on my behalf. I have read and I consent to the collection, use and disclosure of my personal information pursuant to the information detailed at https://www.usi.gov.au/documents/privacy-notice-when-rto-applies-their-behalf
Please select if you authorise Imagine Education to apply for a USI on your behalf

No, I do not authoriseYes, I authorise
Learner Unique Identifier (LUI)
Do you have an LUI?*

YesNo
Please provide your LUI number
e.g. 1235689425
Evidence Collection
Evidence of Identification (Medicare Card, Birth Certificate, Passport or Drivers License)*

Colour Copy Please
Cancelof
Statement of Attainment/transcript (if applicable)

Colour Copy Please
Cancelof
Language, Literacy and Numeracy Skills

It is a Government requirement that we ensure the LLN skills of our students are in line with the course they are about to undertake. Please complete the following tasks:
Youtube
1. What email will you receive from Imagine Education once your enrolment is processed?*
2. What do you need to do after logging into CANVAS for the first time?*
3. Who should you email if you require any support during your enrolment?*
4. Explain the reasons why you want to do this course*
Answer must be a complete sentence and punctuated correctly
Read the following statement and answer the questions below:
Ten-Minute Walk “Tragic Hour”

Ten minutes further down the beach and Kieron Moore could still be alive. This is the time it took for him and his family to walk away from the flagged area where they had been swimming, which was safely patrolled by Surf Lifesavers. This short walk proved to be a tragic mistake that led to the first drowning off Gold Coast beaches during the festive season. According to rescuers, it is a tragedy that could have been avoided.

Tweed Heads resident Shane Christian jumped on his surf board and headed 70m offshore to try to save Mr Moore. But by the time he reached the Toowoomba man, he was unconscious. “If tourists just learn to swim between the flags, maybe this type of thing wouldn’t happen. There should be signs warning of rips up and down the beach”.
5. What mistake did Kieron and his family make?*
6. Where was Kieron Moore from?*
7. How long did it take Kieron Moore to walk away from the flagged area?*
8. How would you make beaches safer so that this sort of event couldn’t happen again?*
9. Please do the following calculations
149+65=*
9x12=*
200-68=*
72÷12= *
½ + ¼ =*
10. If I had two and a half dozen eggs and I broke three of them, how many would be left over?*
11. If you add the number of days in January to the number of days in June, how many days do you have?*
Student Confirmation*

I certify that this work is my own and that I received no assistance from any other person or persons
General Information
CHC30121 - Certificate III in Early Childhood Education and Care
- I have been Informed by the Imagine Education Australia Representitive regarding qualififcations available. The actual selection of units meets our individual needs and requirements.
- I have been informed that should the traineeship be completed in less than 6 months or not be competed at all the employer may miss out on government incentives.
- School based trainees need to complete 100 work days as part of their traineeship, depending on their specific qualification. A work day is based on 7.5 hours per day, which equals 750 hours per traineeship depending on their specific qualification. It is the responsibility of the students and the employer to ensure the days have been completed accordingly.
- I am aware that in the event that Imagine Education Australia cancels a course, I will be offered either equal course, equal qualification or a refund.
- I have been made aware of the material and equipment we must have/provide to complete this qualification.
- I have been given access to DESBT's trainee fact sheet and School-Based Apprenticeships (SAT) fact sheet.
- I am aware that I may require the latest vaccinations stipulated by the workplace or relevant government health authority to enable the student to complete work placement. (ie: Flu, COVID, etc)
I have read and understood the above information
CHC50121 - Diploma of Early Childhood Education and Care
- I have been Informed by the Imagine Education Australia Representitive regarding qualififcations available. The actual selection of units meets our individual needs and requirements.
- I have been informed that should the traineeship be completed in less than 6 months or not be competed at all the employer may miss out on government incentives.
- School based trainees need to complete 100 work days as part of their traineeship, depending on their specific qualification. A work day is based on 7.5 hours per day, which equals 750 hours per traineeship depending on their specific qualification. It is the responsibility of the students and the employer to ensure the days have been completed accordingly.
- I am aware that in the event that Imagine Education Australia cancels a course, I will be offered either equal course, equal qualification or a refund.
- I have been made aware of the material and equipment we must have/provide to complete this qualification.
- I have been given access to DESBT's trainee fact sheet and School-Based Apprenticeships (SAT) fact sheet.
- I am aware that I may require the latest vaccinations stipulated by the workplace or relevant government health authority to enable the student to complete work placement. (ie: Flu, COVID, etc)
I have read and understood the above information
The following person signed off on my enrolment paperwork with the AASN (Australian Apprenticeship Support Network):*
Name and Surname of Mother/Father/Guardian:*
Student Declaration
I am aware that the Student Handbook is located at http://imagineeducation.edu.au/ which includes (please tick all boxes):*

Student Support servicesAccess and equity issuesNCVER Privacy NoticeAssessment process
By signing below, I acknowledge that I have read and agree to the information provided (please tick all boxes)*

I understand that information contained in this form may be provided to State and Commonwealth agencies and research organisations and I consent to that occurring.I agree to abide by Imagine Education Australia policies as outlined in the Student Handbook.I confirm that all information contained in this application is accurate at the time of submitting.I agree for my contact details to be added to an Imagine Education Australia mailing list to receive electronic communication from time to time. I will notify Imagine Education Australia if I do not wish to receivecommunication.I agree for Imagine Education Australia to video and/or take photos for quality training purposes and marketing.If you are under 18 years of age, a parent or legal guardian must sign this form.I agree for my academic progress and results to be shared with my Job Service Agency, Centrelink, School or Employer (whichever applies).
By submitting this application, you are not guaranteed a place within your chosen course until Imagine Education Australia has received and reviewed this application form and you have been provided with confirmation of your acceptance. Whilst every effort is made to ensure that a scheduled course does commence, Imagine Education Australia reserves the right to cancel, postpone, or otherwise modify any courses offered, locations delivered at, and delivery times.
Student Full Name:*
Student Signature:*

Clear
Date Signed:*

DayMonthYear
Date
Parent/Legal Guardian Name:
(If student is under 18)
Parent/Legal Guardian Signature:

Clear
(If student is under 18)
Date Signed

DayMonthYear
Date
Parent/Legal Guardian Phone Number:
(If student is under 18)
Parent/Legal Guardian Email Address:
example@example.com (If student is under 18)
Should be Empty:

School Based Application Form

Please fill out all applicable fields. Fields marked with (*) are mandatory.

Course Selection

Personal Details

Contact Details

Emergency Contact

Language and Cultural Diversity

Disability

Schooling

Study Reason

Previous Qualifications Achieved

Employment Status

Unique Student Identifier (USI)

Learner Unique Identifier (LUI)

Evidence Collection

Language, Literacy and Numeracy Skills

General Information

Student Declaration