HPCH ACFE Enrolment Form

ADULT COMMUNITY & FURTHER EDUCATION:

Our courses are funded by State Government departments. It is necessary for us to supply your information to them as part of fulfilling our obligations to them and therefore obtain the funding for services provided. Your information is kept safe and secure in line with our organisation’s policies.

Course Fee*

Full Fee Concession Fee Exempt/No Fee

Full fee applies to those who do not qualify for government funding, ie. overseas residents or school students OR where the course specifies that it is FULL FEE or Fee for Service only. Concession fee is for those who hold a current Health Care Card, Pensioner Concession Card or Veteran's Gold Card. Exempt/No fee would be where our courses are offered free, and we do not charge any fee. Please clarify with our office staff if you are unsure.

Personal Information

Title*

Mr Mrs Miss Ms Mx

Gender*

Male Female Other

Given Legal name(s)*

First name

Family name*

(legal family name)

Date of Birth

Country of Birth*

Country

Postal Address*

Address Line 1

Address Line 2

State

Postcode

Country

Residential Status*

Australian citizen New Zealand citizen Permanent resident Asylum seeker Not a permanent resident

I will present my Medicare Card as proof of residential status to complete enrolment or I will attach an image of the card with this application form.

Are you of Aboriginal or Torres Strait Islander origin?*

Yes, Aboriginal Yes, Torres Strait Islander Yes, both No

Prior Education Details

What is your highest COMPLETED school level?*

Year 12 or equivalent Year 11 or equivalent Year 10 or equivalent Year 9 or equivalent Year 8 or below Bachelor Degree or Higher Degree Never attended school

Are you still attending school?*

Yes No

Have you ever SUCCESSFULLY COMPLETED any of the specified qualifications? If so, choose the highest level completed*

No, none of them Cert I Cert II Cert III (or Trade Cert) Cert IV (or Advanced Cert/Technician) Diploma (or Associate Diploma) Advanced Diploma and Associate Degree Bachelor Degree or Higher Degree

The specified complete qualification above is recognised as

Australian Australian equivalent International

Employment Details

Have you ever been employed?*

Yes No

Which best describes your current/recent occupations?

1- Managers 2- Professionals 3- Technicians and Trade Workers 4- Community and Personal Service Workers 5- Clerical and Administrative Workers 6- Sales Workers 7- Machinery Operators and Drivers 8- Labourers Other

What best describes your current employment status?*

Full time employee Part time employee Self employed - not employing others Self Employed - Employing others Employed - unpaid worker in a family business Unemployed - seeking part time work Unemployed - seeking full time work Not employed - not seeking employment

Contact Information

Residential Address*

Address Line 1

State

Postcode

Country

Mobile phone

Mobile phone number is preferred so we can send you an SMS if necessary, Please leave a landline number if you don't have a mobile.

Home phone

Please give a landline number if you don't have a mobile.

Is your postal different to your home address?*

Yes - My postal address is the same as my residential address No - My postal address is NOT the same as my residential address

My postal address is the same as my residential address

Address Line 1

Address Line 2

City

State

Postcode

Your email address*

Emergency Contact Details

Emergency Contact Name*

Relationship to you

Emergency Phone Number*

Disability, impairment or long-term condition?

Do you have a disability? *

Yes No

Please specify disabilities

Hearing / deaf Physical Intellectual Learning Mental illness Acquired brain impairment Vision Medical Condition Other:

Other Value

Please let us know if you require any special assistance.

Do you speak a language other than English at home?

Do you speak a language other than English at home?*

Yes No, English only

What language you speak at home*

If English isn't your first language, how well do you speak it?

Very well Well Not well Not at all

How did you hear about Hampton Park Community House (HPCH)?

I am a repeating student Word of mouth Referral Local resident Advertising Regular internet search JSA (Job Services Australia) Facebook advertising Other:

Other Value

Condition of Enrolment and Privacy Statement

Read the Conditions of Enrolment and our Privacy statement

When enrolling I ticked online that*

I declare that the information provided on this form, including that relevant for my eligibility for government funding, is accurate and complete.

When enrolling I ticked online that *

I have read and accept the Conditions of Enrolment at HPC, including the Privacy Statement and the Fee Refund Policy before submitting this enrolment form.

Date*

How would you pay us?

Credit Card / Pay now Electronic funds transfer (EFT)

Account Name: Hampton Park Community Centre
BSB: 063 616
Account Number: 1006 5016
Please use your name as the reference

Fee to be paid* A$

Please enter the amount you would like to pay.

Credit Card / Debit Card*

Add your debit or credit card for the payment. Please be advised that your card information will not be saved and only apl

Signature here*

[clear]

Upload documents here*

No File Chosen

File uploads may not work on some mobile devices.

You can upload supporting documents here.

Personal Information

Prior Education Details

Employment Details

Contact Information

Emergency Contact Details

Disability, impairment or long-term condition?

Do you speak a language other than English at home?

Condition of Enrolment and Privacy Statement

Confirmation Page