Course Enrolment Form

Which course are you attending?*

Course Date*

Date

Status

Course Prefix Code

Course Number*

Who is your Trainer?*

Your First and Last Name (as it appears on your birth certificate/passport)*

First NameLast Name

Do you have any medical conditions, illnesses or injuries that may limit you from taking part in this course?*

NoYes - Please elaborate

Do you identify as having a disability?*

NoYes

Please Elaborate

Birth Date*

DayMonthYear

Do you want your results uploaded to the New Zealand Qualifications Authority (NZQA)?*

YesNo

House / Apartment Number*

Street Name*

Suburb*

Region*

Post Code*

Must be 4 digits

E-mail Address*

example@example.com

Gender*

Note: The Ministry of Education's database currently only accepts Male and Female as responses to this question and as such, we are unable to offer any other selections.

Citizenship*

Phone Number*

Ethnicity*

Please list the name of your Iwi

Company

Leave Blank if Not Applicable

Position

NZQA Ethnicity Code

Emergency Contact Name*

NameContact Number

When did you last attend a first aid course?*

Have you trained with PracMed NZ before?*

How did you hear about us?*

Please let us know who!

6402

6401

6400

23229

25045

15757

17600

Country

Signature*

Have you trained with PracMed Before?