Avenue Neighbourhood House @ Eley Inc. Pre-Accredited Education Enrolment Form (ACFE) This organisation respects your right to information privacy. Information which we collect and hold is kept in accordance with national and state privacy standards and passed to ACFE or Higher Education and Skills Group as per legislative requirements. Please see the House Manager if you wish to receive a copy of our Privacy policy or to gain access to your own information. Course name Date 1. Personal details Title (Mr/Ms/Mrs/Miss) First name Surname Middle name Residential (home) address Suburb State Postcode Postal address (if different from above) Suburb State Postcode Telephone (home) Telephone (mobile) Telephone (work) Email address From time to time we would like to contact you regarding events and activities. Can we do this via email? Date of birth (Day)/ (Month) (Year) Town/City of birth Gender (tick one box only) Male Female (Indeterminate/Intersex/Unspecified) How did you hear about Avenue Neighbourhood House? N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 1 of 7
2. Victorian Student Number 2.1 Enter your Victorian Student Number (if you have one). 3. Employment Of the following categories, which best describes your current employment status? (Tick one box only) Full time employee Part time employee Self employed - not employing others Employer Employed - unpaid worker in a family business t employed, seeking full time work t employed, seeking part time work t employed, not seeking work 4. Industry of employment/ work Which industry of employment do you work in? (If you identified t employed in the previous question please move to question 6.) Agriculture, forestry & fishing Mining Manufacturing Electricity, Gas, Water or Waste Construction Wholesale Trade Retail Trade Accommodation and Fee Service Transport, Postal & Warehousing Information Media and telecommunications. Financial & Insurance Services Rental, hiring & real estate Professional, Scientific & Technical Administrative & Support Service Public Administration & Safety Education and Training Healthcare and Social Assistance Arts and recreation services Other Services 5. Occupation category Which category best describes your job? Manager Professional Technicians & Trade Workers Community & personal service workers Clerical & Administrative Workers Sales Workers Machinery Operators and Drivers Laborer s N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 2 of 7
6. Language and cultural diversity 6.1 In which country were you born? Australia Other (please specify) 6.2 Do you speak a language other than English at home? (If more than one language, indicate the one that is spoken most)., English only (go to question 7), other please specify 6.3 How well do you speak English? Very well Well t well t at all 6.4 Are you of Aboriginal or Torres Strait Islander origin? (For persons of both origins, mark both boxes)., Aboriginal, Torres Strait Islander 7. Schooling 7.1 What is your highest completed school level? (Tick one box only) Year 12 or equivalent Year 11 or equivalent Year 10 or equivalent Year 9 or equivalent Year 8 or below Never attended school If never attended school go to question 6.1 7.2 In which year did you complete that school level? 7.3 What is the name of the school where you completed your highest school level? 7.4 Are you still attending secondary school? N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 3 of 7
8. Disability 8.1 Do you consider yourself to have a disability, impairment or long term condition? 8.2 If you indicated yes above to a disability, impairment or long term condition, please indicate the area from the following list. (You may indicate more than one area). Hearing/deaf Physical Intellectual Learning Mental illness Acquired brain impairment Vision Medical condition Other 8.3 If you answered yes, what support if any do you need to help you to participate fully in our program? Please provide details. 9. Previous qualifications 9.1 Have you successfully completed any other qualifications since leaving school? 9.2 If yes, tick any qualifications successfully completed. Bachelor degree or higher Advanced diploma or associate degree Diploma (or associate diploma) Certificate IV or advanced Certificate III or trade certificate Certificate II Certificate I Certificate other than listed 9.3 The highest qualification I have completed is: (Include full title of qualification, eg. Certificate III in Aged Care, Intermediate VCAL) 9.4 If you ticked completing qualifications since leaving school in 9.2, please indicate which of the following applies. Australian Qualification Australian Equivalent Qualification International Qualification (a qualification gained overseas of which there is no Australian equivalent) N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 4 of 7
10. Study reason Of the following categories, which best describes your main reason for undertaking this course? (Tick one box only) To get a job To develop my existing business To start my own business To try for a different career To get a better job or promotion It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interest or self-development Other reasons 11. Citizenship 11. 1 Are you an Australian Citizen? (Please provide evidence) 11.2 Are you a holder of a permanent Visa or a Special Category Visa? If yes, provide details Visa Type Number 11.3 Do you have a letter of referral stating you are an Asylum Seeker or a Victim of Human Trafficking? 12. Emergency contact Name Relationship Phone: Mobile Please note, in the event of a serious medical emergency we will call an ambulance and contact the above person. 12. 1 Are there any medical conditions which may affect you in class? Is yes, please give details 12.2 What should we do if this condition arises? (Please attach an additional sheet if space is inadequate) N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 5 of 7
13. Fees and Concession 13.1 Who is responsible for paying your fees? Name Address Phone Postcode 13.2 What is your Medicare Number? 13.3 Are you entitled to any of the following concessions? Pensioner Concession Veteran s Gold Card Concession Health Care Card or Disability Support Card Concession 13.4 If yes, please provide card number and type Card Number Type Please attach a copy of current card-please note FULL FEES will be charged without this copy. 14. Privacy 14.1 In order to maintain a quality training program and to ensure that our training is relevant and of the appropriate standard, we may occasionally need to take your work to moderation. Do you agree for this to happen? 14.2 Photograph From time to time we may photograph you and your class. These photos may be used for marketing and advertising purposes. I give permission for photographs of myself to be used by Avenue Neighbourhood House @ Eley Inc. without any personal compensation and acknowledge that this photo will be owned by Avenue Neighbourhood House @ Eley Inc. I also understand that Avenue Neighbourhood House @ Eley may use my photo up to one year after I have ceased training. * *Please note you can withdraw permission by contacting Avenue Neighbourhood House @ Eley in writing, however such withdrawal will not apply to marketing and advertising materials currently in use or in production. 14.3 Privacy Statement Avenue Neighbourhood House @ Eley is required to provide the Victorian Government, through the Department of Education and Training, with student and training activity data which may include information I provide in this enrolment form. Information is required to be provided in accordance with the Victorian VET Student Statistical Collection Guidelines (which are available at http://www.education.vic.gov.au/training/providers/rto/pages/datacollection.aspx). The Department may use the information provided to it for planning, administration, policy development, program evaluation, resource allocation, reporting and/or research activities. For these and other lawful purposes, the Department may also disclose information to its consultants, advisers, N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 6 of 7
other government agencies, professional bodies and/or other organisations. I have been advised by the training organisation that I may be contacted and requested to participate in a National Centre for Vocational Education Research survey or a Department-endorsed project or audit or review. The Education and Training Reform Act 2006 requires Avenue Neighbourhood House @ Eley Inc. to collect and disclose my personal information for a number of purposes including the allocation to me of a Victorian Student Number and updating my personal information on the Victorian Student Register. For more information in relation to how student information may be used or disclosed please contact Avenue Neighbourhood House @ Eley on 9808 2000 or info@theavenue.org.au. I acknowledge and agree to the terms described in this privacy statement: Signature: 15. Student Declaration I declare that the information that I have provided to Avenue Neighbourhood House @ Eley in application for training is to the best of my knowledge true, correct and complete at the time of my enrolment/application. Signature Date N:\ACFE\PRE ACCREDITED Enrolment Form\PreAccredited Education Enrolment Form 2017 v1.docx Page 7 of 7