ENROLMENT FORM
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Inglewood Community Resource Centre Inc. 33 Brooke Street Inglewood 3517 Phone: (03) 5438 3562 Fax: (03) 5438 3560 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 _____________________ Of the following categories, which BEST describes your main reason for undertaking this course? Tick ONE box only. To get a job To get a better job or promotion For personal interest To develop my existing business It was a requirement of my job For self development To start my own business I wanted extra skills for my job Other reasons To try for a different career To get into another course of study If not born in Australia: How well do you speak English? (Please tick one of the following) p Very well p Well p Not well p Not at all Are you an Aboriginal or Torres Strait Islander? p No p Yes, Aboriginal p Yes, Torres Strait Islander Do you have a disability? p No p Yes (If yes please tick below all areas that apply) p Hearing/deafness p Physical p Intellectual p Mental illness p Acquired brain impairment p Vision p Medical condition p Other Please let us know if you require assistance to access courses. Are You: (Please tick one of the following) p Full time employee p Unpaid family worker p Part time employee p Unemployed - seeking full time work p Self employed - with no employees p Unemployed - seeking part time work p Self employed - with employees p Not employed - not seeking work What is your highest completed school level? (Please tick below) p Year 12 p Year 11 p Year 10 p Year 9 or less Please tick any of the following qualifications you have completed: p Bachelor degree or higher degree p Advanced diploma or associate degree p Diploma or associate diploma p Certificate IV (or advanced certificate) p Certificate III (or trade certificate) p Certificate II p Certificate I p Other …………………………….. Please continue form overleafFEE EXEMPTION or CONCESSION TYPE F. Family allowance supplement - Parenting payment single Q Sickness allowance P Age pension - Care pension - Disability support pension - Partner allowance - Youth allowance S Low income – Special benefit N Newstart age allowance - Mature age allowance - Newstart allowance - Newstart mature allowance Z None O Other Enrolment Details COURSE/S BOOKING COST CASH/CHEQUE RECEIPT NO. ____________________________________ ___________ ___________ _________ ____________________________________ ___________ ___________ 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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