Hme Mdificatins Enrlment Frm Please answer all questins t cmplete yur Hme Mdificatins enrlment Persnal details 1. Enter yur full name Family Name (Surname) Given Names 2. Enter yur birth date Day/mnth/year 3. Sex (Tick ONE bx nly) Male Female Unspecified M F X 4. What is the address f yur usual residence? Please prvide the physical address (street number and name nt pst ffice bx) where yu usually reside rather than any temprary address at which yu reside fr training, wrk r ther purpses befre returning t yur hme. If yu are frm a rural area use the address frm yur state s r territry s rural prperty addressing r numbering system as yur residential street address. Building/prperty name Flat/unit details Street r lt number (e.g. 205 r Lt 118) Street name Suburb, lcality r twn State/territry Pstcde 5. What are yur cntact details? Phne Mbile Fax Email Unique Student Identifier (USI) 6. What is yur Unique Student Identifier? USI: If yu d nt have a Unique Student Identifier, yu may apply fr ne at http://www.usi.gv.au and ntify AT Australia befre curse cmmencement. (This shuld nly take abut 5 t 10 minutes t cmplete.) Hme Mdificatins Enrlment Frm, Versin 2.5 1 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse Language and cultural diversity 7. In which cuntry were yu brn? Australia 1101 Other please specify In which twn/city were yu brn? 8. D yu speak a language ther than English at hme? (If mre than ne language, indicate the ne that is spken mst ften) N, English nly 1201 English nly G t questin 11 Yes, ther please specify 9. Hw well d yu speak English? Very well 1 Well 2 Nt well 3 Nt at all 4 10. Are yu f Abriginal r Trres Strait Islander rigin? (Fr persns f bth Abriginal and Trres Strait Islander rigin, mark bth Yes bxes) N Yes, Abriginal Yes, Trres Strait Islander Disability 11. D yu cnsider yurself t have a disability, impairment r lng-term cnditin? Yes Y N N N G t questin 14 12. If yu indicated the presence f a disability, impairment r lng-term cnditin, please select the area(s) in the fllwing list (Yu may indicate mre than ne area): Hearing/deaf Physical Intellectual Learning Mental illness Acquired brain impairment Visin Medical cnditin Other Hme Mdificatins Enrlment Frm, Versin 2.5 2 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse Schling 13. What is yur highest COMPLETED schl level? (Tick ONE bx nly) Year 12 r equivalent Year 11 r equivalent Year 10 r equivalent Year 9 r equivalent Year 8 r belw Never attended schl 14. In which YEAR did yu cmplete that schl level? 15. Are yu sti l attending se cndary schl? Yes N Y N Previus qualificatins achieved 16. Have yu SUCCESSFULLY cmpleted any f the fllwing qualificatins? Yes Y N N N gtquestin18 17. If YES, then tick ANY applicable bxes. Bachelr degree r higher degree Advanced diplma r assciate degree Diplma (r assciate diplma) Certificate IV (r advanced certificate/technician) Certificate III (r trade certificate) Certificate II Certificate I Certificates ther than the abve Emplyment 18. Of the fllwing categries, which BEST describes yur current emplyment status? (Tick ONE bx nly) Full-time emplyee Part-time emplyee Self emplyed nt emplying thers Emplyer Emplyed unpaid wrker in a family business Unemplyed seeking full-time wrk Unemplyed seeking part-time wrk Nt emplyed nt seeking emplyment Hme Mdificatins Enrlment Frm, Versin 2.5 3 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse 19. Current Emplyment Details AT Australia will cntact yur emplyer t cmplete a questinnaire. Their feedback will play an imprtant rle in develping the quality f training at AT Australia. Occupatin Organisatin Name Emplyer s Cntact Name Emplyer s Cntact Phne Emplyer s Email Study reasn 20. Of the fllwing categries, which BEST describes yur main reasn fr undertaking this curse/traineeship/apprenticeship? (Tick ONE bx nly) T get a jb T develp my existing business T start my wn business T try fr a different career T get a better jb r prmtin It was a requirement f my jb I wanted extra skills fr my jb T get int anther curse f study Fr persnal interest r self-develpment Other reasns 21. Are yu intending t cmplete the assessment r undertake the curse wrk nly? (Tick ONE bx nly) Cmplete Assessment 01 Curse wrk nly 02 If curse wrk nly, please explain why (eg CPD pints) Hme Mdificatins Enrlment Frm, Versin 2.5 4 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse Payment Infrmatin Curse Details Curse Name Curse Duratin Fee payable Hme Mdificatins Curse Tw Days $890.00 (including GST) An invice will be sent as sn as curse applicatin received. Payment will need t be received prir t curse registratin being issued. Curse Dates 2018 Please indicate the curse yu want t attend: Curse Cde Lcatin Date Payment Methd Invice Please prvide the fllwing details : Invice t: Cmpany Name: Full Address: Email t send invice: Cheque (Make cheques payable t Independent Living Centre NSW) Visa Mastercard Name n Card: Direct Depsit Payable t Independent Living Centre NSW St Gerge Bank, BSB 112 879 Acct N. 4295 40510 Card N: Exp Date: / Amunt: $ Signature: Registratin will nt be finalised until payment is received. A receipt will be issued. Cancellatin and refunds: when a cancellatin r refund is unavidable, yu can: Substitute a persn in the curse Request a refund up t 7 days prir t the curse (less 10% admin fee) Request a transfer t anther curse Special cnsideratins: if yu have any special needs r dietary requirements please attach the relevant infrmatin t yur registratin frm. Hme Mdificatins Enrlment Frm, Versin 2.5 5 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse Privacy Ntice If yu d nt already have a Unique Student Identifier (USI) and yu want Assistive Technlgy Australia (AT Australia) t apply fr a USI t the Student Identifiers Registrar (Registrar) n yur behalf, AT Australia will prvide t the Registrar the fllwing items f persnal infrmatin abut yu: yur name, including first r given name(s), middle name(s) and surname r family name as they appear in an identificatin dcument; yur date f birth, as it appears, if shwn, in the chsen dcument f identity; yur city r twn f birth; yur cuntry f birth; yur gender; and yur cntact details. When we apply fr a USI n yur behalf the Registrar will verify yur identity. The Registrar will d s thrugh the Dcument Verificatin Service (DVS) managed by the Attrney-General s Department which is built int the USI nline applicatin prcess if yu have dcuments such as a Medicare card, birth certificate, driver s licence, Australian passprt, citizenship dcument, certificate f registratin by descent, ImmiCard r Australian entry visa. If yu d nt have a dcument suitable fr the DVS and we are authrized t d s by the Registrar we may be able t verify yur identity by ther means. If yu d nt have any f the identity dcuments mentined abve, and we are nt authrized by the registrar t verify yur identity by ther means, we cannt apply fr a USi n yur behalf and yu shuld cntact the Student Identifiers Registrar. In accrdance with sectin 11 f the Student Identifiers Act 2014 Cth (SI Act), we will securely destry persnal infrmatin which we cllect frm yu slely fr the purpse f applying fr a USI n yur behalf as sn as practicable after the USI applicatin has been made r the infrmatin is n lnger needed fr that purpse, unless we are required by r under any law t retain it. The persnal infrmatin abut yu that we prvide t the Registrar, including yur identity infrmatin, is prtected by the Privacy Act 1988 Cth (Privacy Act). The cllectin, use and disclsure f yur USI are prtected by the SI Act. If yu ask AT Australia t make an applicatin fr a student identifier n yur behalf, AT Australia will have t declare that AT Australia has cmplied with certain terms and cnditins t be able t access the nline student identifier prtal and submit this applicatin, including a declaratin that AT Australia has given yu the fllwing privacy ntice: Yu are advised and agree that yu understand and cnsent that the persnal infrmatin yu prvide t us in cnnectin with yur applicatin fr a USI: is cllected by the Registrar fr the purpses f: applying fr, verifying and giving a USI; reslving prblems with a USI; and creating authenticated vcatinal educatin and training (VET) transcripts; may be disclsed t: Cmmnwealth and State/Territry gvernment departments and agencies and statutry bdies perfrming functins relating t VET fr: the purpses f administering and auditing Vcatinal Educatin and Training (VET), VET prviders and VET prgrams; educatin related plicy and research purpses; and t assist in determining eligibility fr training subsidies; VET Regulatrs t enable them t perfrm their VET regulatry functins; VET Admissin Bdies fr the purpses f administering VET and VET prgrams; current and frmer Registered Training Organisatins t enable them t deliver VET curses t the individual, meet their reprting bligatins under the VET standards and gvernment cntracts and assist in determining eligibility fr training subsidies; schls fr the purpses f delivering VET curses t the individual and reprting n these curses; the Natinal Centre fr Vcatinal Educatin Research fr the purpse f creating authenticated VET transcripts, reslving prblems with USIs and fr the cllectin, preparatin and auditing f natinal VET statistics; researchers fr educatin and training related research purpses; Hme Mdificatins Enrlment Frm, Versin 2.5 6 f 7 July 2018
Assistive Technlgy Australia Hme Mdificatins Curse any ther persn r agency that may be authrized r required by law t access the infrmatin; any entity cntractually engaged by the Student Identifiers Registrar t assist in the perfrmance f his r her functins in the administratin f the USI system; and will nt therwise be disclsed withut yur cnsent unless authrized r required by r under law. Privacy Plicies and Cmplaints Yu can find further infrmatin n hw the Registrar cllects, uses and disclses the persnal infrmatin abut yu in the Registrar s Privacy Plicy (visit http://www.usi.gv.au/pages/privacy-plicy.aspx)r by cntacting the Registrar. The Registrar s Privacy Plicy cntains infrmatin abut hw yu may access and seek crrectin f the persnal infrmatin held abut yu and hw yu may make a cmplaint abut a breach f privacy by the Registrar in cnnectin with the USI and hw such cmplaints will be dealt with. Yu may als make a cmplaint t the Infrmatin Cmmissiner abut an interference with privacy pursuant t the Privacy Act, which includes the fllwing: misuse r interference f r unauthrized cllectin, use, access, mdificatin r disclsure f USIs; and a failure by AT Australia t destry persnal infrmatin cllected by AT Australia nly fr the purpse f applying fr a USI n yur behalf. Fr infrmatin abut hw AT Australia cllects, uses and disclses yur persnal infrmatin generally, including hw yu can make a cmplaint abut a breach f privacy, please refer t AT Australia s privacy plicy which can be btained by cntacting AT Australia n (02) 9912 5800 r by email t training@at-aust.rg. Declaratin I have read and understand the details prvided t me in the Student Handbk and Training Guide I have read, understand and accept the Privacy Ntice prvided in this Frm I understand the cnditins, assessment and appeals prcess I agree t participate in the training and assessment Student s Signature Date Wuld yu like t receive AT Australia training mailuts fr upcming curses (via email)? Yes, add me t yur mailut list N, I am nt interested Assistive Technlgy Australia, Shp 4019, Lvl 4, Westpint Shpping Centre, 17 Patrick Street, Blacktwn NSW 2148 Infline: 1300 452 679 Receptin: (02) 9912 5800 Fax: (02) 8814 9656 PO Bx 8034, Blacktwn Westpint NSW 2148 Email: training@at-aust.rg mailt:training@at aust.rg Web: http://www.at-aust.rg ABN 44 103 681 572 Hme Mdificatins Enrlment Frm, Versin 2.5 7 f 7 July 2018