ENROLMENT FORM

Inglewood Community Resource Centre Inc.


33 Brooke Street Inglewood 3517
Ph (03)5438 3562
Fax (03)5438 3260
inglewoodcrc@impulse.net.au
.

ENROLMENT FORM



This form and payment are required to secure your place in a course. Full payment must be made before the first class, unless instalments have been agreed in advance. The fee will be returned if the course is fully booked or cancelled.

Name______________________________________________
(First Names) (Last name)

Address___________________________________________

________________________________ Postcode _______

Phone No ( ) _________________ (H) ( ) ________________ (W)

Email ________________________________

Date of Birth ____/____/____ Female / Male (please circle)

Country of Birth _____________________ Language spoken at home _____________________

If not born in Australia: How well do you speak English? (Please tick one of the following)
O Very well O Well O Not well O Not at all

Are you an Aboriginal or Torres Strait Islander?
O No O Yes, Aboriginal O Yes, Torres Strait Islander

Do you have a disability?
O No O Yes (If yes please tick below all areas that apply)
O Hearing/deafness O Physical O Intellectual
0 Mental illness 0 Acquired brain impairmenT O Vision
O Medical condition 0 Other
Please let us know if you require assistance to access courses.

Are You: (Please tick one of the following)
O Full time employee O Unpaid family worker
O Part time employee O Unemployed - seeking full time work
O Self employed - with no employees O Unemployed - seeking part time work
O Self employed - with employees O Not employed - not seeking work

What is your highest completed school level? (Please tick below)
O Year 12 O Year 11 O Year 10 O Year 9 or less

Please tick any of the following qualifications you have completed:
O Bachelor degree or higher degree
O Advanced diploma or associate degree
O Diploma or associate diploma 0 Certificate IV (or advanced certificate)
O Certificate III (or trade certificate)
0 Certificate II
O Certificate I
0 Other ……………………………..


Enrolment Details


COURSE/S BOOKING COST CASH/CHEQUE
____________________________________ ___________ ___________
____________________________________ ___________ ___________

TODAY’S DATE ____/ ____/ ____
Name of person taking enrolment/payment : _________________________________________________
PRIVACY: ICRC respects your right to information privacy. Information that we collect & hold about learners is kept in accordance with our privacy policy and information privacy laws. Please contact us if you would like more information about our privacy policy.

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