Enrolment Application Form

Title	Mr Mrs Ms Miss
Surname
First Name
Sex	Male Female
Email:
Address:
Suburb:
Postcode:
Telephone:
(B/H):
(A/H):
Mobile:
D.O.B.:
Country of Birth:
Are you an Australian Citizen or Permanent Resident?	Yes No
Do you speak a language other than English at home?	No, English Only Yes
If you answered 'Yes' to the previous question, please specify the language(s) you speak:
How Well do you speak English?	Very Well Well Not Well Not at All
Are you Aboriginal or Torres Strait Islander?	No Yes, Aboriginal Yes, Torres Strait Islander
Do you consider yourself to have a disability, impairment or long-term condition?	No Yes
If you answered 'Yes' to the previous question, please indicate the areas of disability, impairment or long-term condition: (You may indicate more than one area).	Hearing / Deaf Mental Illness Physical Acquired Brain Injury Intellectual Vision Learning Medical Condition Other, please specify
Education
What is your highest completed school level?	Year 12 Year 11 Year 10 Year 9 or equivalent Year 8 or Lower Did not go to school
In which year did you complete this school level?
Have you successfully completed any of the following qualifications?	Yes No If YES, then tick any applicable boxes. Bachelor Degree or Higher Degree Advance Diploma or Ass. Diploma Diploma (or Ass. Diploma) Certificate I Certificate II Certificate III (or Trade Certificate) Certificate IV (or Advanced Certificate / Technician) Certificates other than the above, please specify
I declare that I have truthfully disclosed information about my highest prior qualifications and that the information I have provided is complete and accurate.	Yes No
Employment Status
Of the following categories, which best describes your current employment status?	01 Full Time Employee 02 Part Time Employee 03 Self Employed - not employing others 04 Employer 05 Employed - Unpaid Family Worker 06 Unemployed (Seeking F/T Work) 07 Unemployed (Seeking P/T Work) 08 Not Employed Not Seeking Employment
Of the following, which best describes your main reason for undertaking this course / traineeship / apprenticeship?	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 For self development To get a qualification Other reasons
Current Enrolment
Have you participated in a course with employ-ease previously?	Yes No
How did you find out about this course?
Please enrol me (my family member) in the following course: One course per enrolment form/one person per enrolment form.	Title of Course Course Code
Emergency Contact Information
Emergency Contact 1:
Name:
Relationship to you:
Home phone:
Work phone:
Mobile phone:
Emergency Contact 2:
Name:
Relationship to you:
Home phone:
Work phone:
Mobile phone:
Details of any medical conditions that may affect me: (please include any known allergies)
I authorise the teacher/trainer in charge of the program in which I am participating as a student of Employ-ease Pty Ltd, to arrange for such medical or surgical treatment as may be deemed necessary in the event of me being incapacitated. I understand that this information will be securely destroyed upon completion of the course I am undertaking through Employ-Ease Pty Ltd.
You must check this box to validate enrolment	I agree
Please place any additional queries below...