Office Use Only Eligible for Funding Reason: Yes No EDUCATION ENROLMENT FORM EXPRESSION OF INTEREST Office Use Only Student Number: Enrolment Complete: Yes No Course: Classroom: Start Date: Documents uploaded Yes No DATE: COMPLETED BY: (Name of Youth Worker) PERSONAL DETAILS Given name/s: Middle Name: Surname: Maiden Name: Gender: Male Female Date of Birth: Tax File Number: Victorian Student Number: Unique Student Identifier: (This is compulsory for your enrolment. Please advise staff if you require assistance in creating a USI) Address: Suburb: State: Postcode: Home Ph: Mobile: Email: EMERGENCY CONTACT DETAILS Given name/s: Surname: Relationship to Student: Address: Suburb: State: Postcode: Home Ph: Mobile: Email: REFERRING WORKERS DETAILS Name of Agency: Contact Person: Phone No: Email: Do you give us permission to contact this person if we need to discuss any concerns we may have with your progress and/or participation in our program? Yes No 1
EDUCATION ENROLMENT FORM 2
EDUCATION ENROLMENT FORM HEALTH CARE Health Care Card Number: Expiry Date: Medicare Card Number: Expiry Date: EMPLOYMENT STATUS Employed full time Employed unpaid worker in family business Employed part time Unemployed seeking full time work Self-employed not employing others Unemployed seeking part time work Employer Unemployed not seeking work Never employed go to Schooling Which of the following classifications BEST describes your current or recent occupation? (tick one box only) Managers Professionals Technicians and Trade Workers Community and Personal Service Workers Clerical and Administrative Workers Sales Workers Machinery Operators and Drivers Labourers Other Which of the following classifications BEST describes the Industry of your current or recent Employer? (tick one box only) A - Agriculture, Forestry and Fishing B Mining C Manufacturing D Electricity, Gas, Water & Waste Services E Construction F Wholesale Trade G Retail Trade H Accommodation and Feed Services I Transport, Postal and Warehousing J Information Media and telecommunications K Financial and Insurance Services L Rental, Hiring and Real Estate Services M Professional, Scientific and Technical Services N Administrative and Support Services O Public Administration and Safety P Education and Training Q Health Care and Social Assistance R Arts and Recreation Services S Other Services 3
SCHOOLING EDUCATION ENROLMENT FORM Are you still at school? Yes No Highest school level completed? (you must have completed this level of schooling not just attended or attempted.) What year did you complete this level of schooling? (ie. 2012) Name of school you completed this education: PRIOR EDUCATION Have you successfully completed any prior education? Yes No If yes, please specify industry and level of qualification: Bachelor Degree or Higher Degree Advanced Diploma Certificate IV Certificate III Certificate II Certificate I Certificate other than the above I have provided a copy of the above certificate Yes No Is this education recognised in: Australia Internationally Australian equivalent LANGUAGE Country of Birth: If not Australia please supply Citizenship papers What is your primary language?: How well do you speak English?: Very Well Well Not Well Not at all International English Test Score: (IELTS / TOEFL) 4
MEDICAL EDUCATION ENROLMENT FORM Do you have a disability, impairment or long-term Yes No If yes, please indicate the areas of disability, impairment or long-term condition: Hearing/deaf Mental Illness Acquired brain impairment Physical Learning Intellectual Medical condition Vision Other (please state) Do you have any allergies? Yes No If yes, please describe: Do you currently have any personal barriers that you may need support with? Housing Legal Mental Health Financial Health Drug & Alcohol Caring for others Other ATSI STATUS Please indicate if you are: Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Neither Aboriginal nor Torres Strait Islander INTERNATIONAL Passport No.: Expiry Date: Country of Issue: Visa Number: Visa Type: Visa Expiry Date: NEXT OF KIN leave blank if same as Emergency Contact Given name/s: Surname: Relationship to Student: Address: Suburb: State: Postcode: Home Ph: Mobile: Email: Occupation: Passport No. Country of Issue: 5
EDUCATION ENROLMENT FORM CLIENT TUITION FEE PRIMARY CONTRIBUTOR Please indicate the party responsible for contributing the majority of the tuition fee: Student or their family; private benefactor/sponsor Employer, industry or corporate sponsor Community/not for profit organisation Employment services provider No fee was charged Other If you are enlisted in a Workers in Transition program, please provide your Employers ABN STUDY REASON 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 6
EDUCATION ENROLMENT FORM WORKERS CONTACT DETAILS There are several types of workers that would be helpful for us to know about. If you have any of the following workers and you would allow us to connect with them, please fill in the information below. This is also important as some of these workers will be able to arrange payment of fees on your behalf. Out of Home Care: DHS Services (eg, Youth Justice, Child Protection): Springboard: Job Services Australia: Other worker you think might be able to help in this education process: 7
ELIGIBILITY TO STUDY/PROOF OF IDENTITY EDUCATION ENROLMENT FORM We need proof of your identity to verify your eligibility to study in Australia. Examples of acceptable ID include: Australian Birth Certificate Current Australian Passport Medicare Card Drivers Licence Health Care Card Proof of Age card Keypass card **Certificate of Australian Citizenship ** If you were not born in Australia, we need to sight and copy your Citizenship papers for eligibility to study In addition, please complete the attached VTG form (which will assess your eligibility for government funding) and supply us with at least 1 form of suitable photo ID or your birth certificate plus your Health Care Card which we will copy and keep on file. PRIVACY STATEMENT I understand that Melbourne City Mission is required to provide the Victorian Government, through the Department of Education and Early Childhood Development, 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, other government agencies, professional bodies and/or other organizations. I have been advised by Melbourne City Mission 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 Melbourne City Mission 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. DECLARATION By signing here, I state that the information given on this enrolment form is accurate and true and I acknowledge and agree to the terms of the Privacy Statement. If accepted into Melbourne City Mission s education program, I give permission for information regarding my progress to be discussed with the relevant people listed in this application form. I understand that the information will be treated with strict confidence. Name of Student Signature of Student Date If you are under 16 years of age, we require this application to be signed by a parent or legal guardian on your behalf. Name of Parent/Legal Guardian Signature of Parent/Legal Guardian Date 8