Back on Track Drink Driver Program Enrolment Form

Before completing this form:

Check with the Motor Vehicle Registration Office (MVR) whether you need to complete Unit 1 only OR both Unit 1 & 2 of the course. They can be contacted on 1300 654 628.
PARTICIPANT ENROLMENT FORM

BACK ON TRACK DRINK DRIVER PROGRAM
All fields marked with a red asterisk are required to be completed.
Select course location:*

Darwin- 12 Salonika St, ParapKatherine - Knotts Crossing ResortPalmerston- CDU Campus
Select units required to complete:*

Unit 1 - Cost $300Unit 1 & 2 - Cost $370
Select units required to complete:*

Unit 1 - Cost $350Unit 1 & 2 - Cost $420
Select a Course Date (Katherine)*

25th & 26th June 2020
Select a Course Date (Darwin)*

30 & 31 May 2020
Participant details
First name:*
Middle name/s:
Surname:*
Date of Birth:*

DayMonthYear
Gender:*

MaleFemale
Contact details
Please enter a contact phone number and an email address.
Contact Phone Number:*
Email address:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is your home address the same as your postal address?

YesNo
Postal Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Language and cultural diversity
Do you identify as:*

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait Islander
Country of birth:*
Language spoken at home:*
How well do you speak English?*

Very wellWellNot wellNot at all
Do you need help reading and writing English?*

YesNo
Education and employment
Are you attending school?*

YesNo
What year did you finish school?
What is your highest COMPLETED school level?*

Year 12Year 11Year 10Year 9Year 8 or belowDid not go to school
Have you completed any qualifications?*

YesNo
If yes, what qualifications?

Bachelor or higher degreeAdvanced diploma or Associate degreeDiploma or Associate diplomaCertificate IV (or advanced cert/technician)Certificate III (or trade certificate)Certificate IICertificate IOther
What is your current employment status?*

Full-time employeePart-time employeeSelf-employed - not employing othersEmployerEmployed - unpaid family workerUnemployed - seeking full-time workUnemployed - seeking part-time workNot employed - not seeking employment
Disabilities, impairments or conditions
Do you consider yourself to have a permanent or long term disability, impairment or condition?*

YesNo
If yes, select any applicable:

Hearing/deafMental illnessVisual/sight/seeingPhysicalAcquired brain impairmentMedical conditionLearningUnspecifiedOther
Drink or drug driving history
How many times have you been charged with drink or drug driving offences?*

012345 or more
On the most recent occasion what was your blood/breath alcohol content reading?*

Not applicableNot sure< 0.08 Low range0.08-0.149 (M) Medium range> 0.15 (H) High range
Agreement and declaration
Participation agreement

I agree to come to all program sessions on time and to the end of the session.

I agree to be drug and alcohol free with a BAC of 0.00 when attending the course and agree to be breath tested if this is requested.

I agree to forfeit all rights to a refund of course fees if I register a BAC above 0.00 or fail to meet all requirements set out in the participation agreement and declaration.

I will provide 2 days notice if i wish not to attend the course I am registered on, I understand if I dont provide notice my moneys will be forfeited.

I will bring photo ID to the program.

I will be polite and show respect to all other group members and the facilitator/s.

I agree that I will take part in group discussions and complete all the program activities and tasks, including any homework tasks, that I am asked to do.

I acknowledge that I may be excluded from the program if I do not abide by the conditions above and that I will not receive a Notice of Completion of the course.

Declaration

I consent to the Back On Track Drink Driver Program using and disclosing information from my program records for the purpose of effectively delivering the program; this may include providing personal and contact details to third party providers authorised by the Department of Transport to deliver services under the program.

I consent to the Drink Driver Program using and disclosing information from my program records for driver / rider licensing purposes.
Date:*

DayMonthYear
Use your mouse/finger to sign your name in the box below if you understand and agree to the above agreement and declaration.
Signature:*
Privacy

The Back On Track Drink Driver Program is authorised by the Department of Transport to collect the information on this form or otherwise provided by you as part of the enrolment. Any information you provide is on a voluntary basis but is needed to process your application.

Some of the personal information provided by you on this application may be provided to other NT Government agencies, such as Department of Corrections and Department of Health. This information is used for statistical, administrative and other purposes. If you have any questions or concerns about the use of your information as detailed about, please contact the Back On Track Drink Driver Program on (08) 8944 8750 or by email to drinkdriverprogram@nt.gov.au
Identification

You must bring PHOTO ID with date of birth visible to both days of the course.

Failure to bring photo ID will result in you being unable to sit the course.

This could be an 18+ card, passport, ochre card, other licence or old drivers licence. (birth certificates not accepted)

If you do not have photo ID you must visit the Motor Vehicle Registration Office (MVR) to obtain a proof of age card before course commencement.
Payment Options

This registration does NOT confirm your booking on the course. Places are LIMITED call the office to make payment and secure your booking- 8941 1752.
Program Fees owing - $300 (Unit 1 - Darwin)
Program Fees owing - $370 (Unit 2 - Darwin)
Program Fees owing - $350 (Unit 1 - Katherine)
Program Fees owing - $420 (Unit 2 - Katherine)
Please indicate how you will pay for the course before the date:*

Internet Banking Transfer into our accountCash deposit at Westpac bankCash, EFTPOS, Credit Card at the office
Pay by Internet Transfer or direct deposit at Westpac

Please write our bank details down:

Bank: Westpac

Account Name: EASA Inc

BSB: 035 309

Account number: 117792

Use your full name or surname as a reference for the transaction.
Pay by Credit Card over the phone or visiting our office

Address: 12 Salonika St, The Avenue Parap

PH: 8941 1752
Please click the Submit button below and wait until the thank you screen appears.

You can be assured your information is transmitted securely with 256bit encryption.

If the Thank you screen does not appear, scroll up and check whether all required fields are entered.
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PARTICIPANT ENROLMENT FORM