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Southern Grampians Adult Education Inc. Enrolment Form 2018
Participant Personal Details/Enrolment Form

Information collected is within the guidelines of the Privacy Principles contained in the
Privacy Act 1988 and will be used solely for RTO training activities.
An application for courses is accepted from any student who meets the course pre-requisites. Course places are limited and the demand may be high, candidates should apply early to ensure a place in the course of their choice.

Application Checklist
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Please return this completed form with attachments to:

Southern Grampians Adult Education Inc.
48 Thompson Street (PO Box 601)
Hamilton Victoria 3300
Telephone : (03) 5571 9900
Email : sgae@sgae.vic.edu.au
Web : www.sgae.vic.edu.au
RTO Code : 20645

1. UNIQUE STUDENT IDENTIFIER (USI)

From 1 January 2015, all Registered Training Organisations can be prevented from issuing you with a nationally recognised VET qualification or statement of attainment when you complete your course if you do not have a Unique Student Identifier (USI). If you have not yet obtained a USI you can apply for it directly at http://www.usi.gov.au/create-your-USI/ on computer or mobile device. Please note that if you would like to specify your gender as ‘other’ you will need to contact the USI office for assistance.


Enter your Unique Student Identifier (USI)
If you do not have a USI, require assistance, or would like us to apply on your behalf, please speak with administration staff.

USI
Your answer
2. STATE FUNDING BODY IDENTIFIER

Enter your state-specific learner identifier

If you are unaware of, or do not have this student number
State-specific Learner Identifier
Your answer
3. INTENDED COURSE OF STUDY
Course Description
Your answer
Course Code
Your answer
Commencement date
Your answer
Termination/Completion date
Your answer
4. RECOGNITION & CREDIT TRANSFER

Do you wish to apply for:
(Please refer to Student Handbook for further information on the procedures for application of RPL or CT).

Recognition of Prior Learning (RPL)
Credit Transfer (CT)
5. PERSONAL DETAILS
Title
Family Name*
Your answer
Given Name(s)*
Your answer
*

Please write the name that you used when you applied for your Unique Student Identifier (USI), including any middle names.

6. BIRTH DATE
Date
Your answer
Month
Your answer
Year
Your answer
GENDER (Tick ONE box only)
GENDER (Tick ONE box only)
8. CONTACT DETAILS
Landline (inc. area code)
Your answer
Mobile
Your answer
Email Address
Your answer
Alternative email address
Your answer
9. ADDRESS OF YOUR USUAL RESIDENCE
Flat/Unit details
Your answer
Building/Property name
Your answer
Street number
Your answer
Street name
Your answer
Suburb/town
Your answer
State/territory
Your answer
Postcode
Your answer
10. POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
Flat/Unit details
Your answer
Building/Property name
Your answer
Street number
Your answer
Street name
Your answer
Suburb/town
Your answer
State/territory
Your answer
Postcode
Your answer
11. PARENT/GUARDIAN (IF PARTICIPANT IS UNDER 18 YEARS OF AGE)
Name
Your answer
Relationship
Your answer
Address
Your answer
Suburb
Your answer
Postcode
Your answer
Contact No.
Your answer
Email address
Your answer
12. EMERGENCY CONTACT INFORMATION
Name
Your answer
Contact No.
Your answer
Relationship
Your answer
13. CONCESSION
Do you believe you are eligible for concession?
If so, what type of concession:
14. LANGUAGE AND CULTURAL DIVERSITY
In which country were you born?
Do you speak a language other than English at home?
Are you of Aboriginal or Torres Strait Islander origin?
(for persons of both Aboriginal and Torres Strait Islander origin, mark  YES, Aboriginal both ‘Yes’ boxes)
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15. DISABILITY
Do you consider yourself to have a disability, impairment or long-term condition?
If you indicated the presence of a disability, impairment or long-term condition, please select the area(s) in the following list: (You may indicate more than one area)
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If you answered YES to the above question, do you require any assistance to participate in this course?
16. EDUCATION HISTORY
What is your highest COMPLETED school level? (Tick ONE box only)
Are you still enrolled in secondary or senior secondary education?
17. PREVIOUS QUALIFICATIONS ACHIEVED
Have you SUCCESSFULLY completed any of the following qualifications?
If yes, please enter one of these Prior Education Achievement Recognition Identifiers to any applicable qualification level.

A = Australian

E = Australian equivalent

I = International

Bachelor degree or higher degree
Your answer
Certificate II (or trade certificate)
Your answer
Advanced diploma or associate degree
Your answer
Certificate II
Your answer
Diploma (or associate diploma)
Your answer
Certificate I
Your answer
Certificate IV (or advanced certificate/technician)
Your answer
Certificates other than the above
Your answer
If qualification not gained in Australia, please identify which country it was achieved in:
Your answer
18. EMPLOYMENT
Employment
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19. OCCUPATION
Which of the following BEST describes your current or recent occupation (Tick ONE box only)
20. INDUSTRY
Industry
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21. STUDY REASON
Reasons for study
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22. PRIVACY STATEMENT & STUDENT DECLARATION

Under the Data Provision Requirements 2012, Southern Grampians Adult Education Inc. is required to collect personal information about you and to disclose that personal information to the National Centre for Vocational Education Research Ltd. (NCVER).
Your personal information (including the personal information contained on this enrolment form and your training activity data) may be used or disclosed by Southern Grampians Adult Education Inc. for statistical, regulatory and research purposes. Southern Grampians Adult Education Inc. may disclose your personal information for these purposes to third parties, including:


 School – if you are a secondary student undertaking VET, including a school-based apprenticeship or traineeship;
 Employer – if you are enrolled in training paid by your employer;
 Commonwealth and State or Territory government departments and authorised agencies;
 NCVER;
 Organisations conducting student surveys; and
 Researchers.


Personal information disclosed to NCVER may be used or disclosed for the following purposes:

www.ncver.edu.au )


I declare that the information I have provided to the best of my knowledge is true and correct.
I consent to the collection, use and disclosure of my personal information in accordance with the Privacy Notice above.
Marketing use content
I give Southern Grampians Adult Education Inc. permission to use photos in public material and social media (including any photos in which I may be recognised) as may be useful.
I authorise images of my participation in training to be used by Southern Grampians Adult Education Inc. for future marketing and business purposes.
I understand that I retain the right to withdraw my consent at any time.

Consent
Student Signature
Draw your signature below
Date
Your answer
Parent/Guardian Signature (*Parental/guardian consent is required for all students under the age of 18.)
Draw your signature below
Date
Your answer
OFFICE USE ONLY – THIS SECTION IS ONLY TO BE COMPLETED BY THE RTO
Date PTR completed
Your answer
LLN proficiency completed
Your answer
Date digital literacy completed
Your answer
Support services required
Flexible adjustment required
Your answer
Student accepted
Commencement date
Your answer
SMRS details entered by 
Your answer
Termination/completion date
Your answer
Date SMRS details entered
Your answer

By checking this, you are agreeing to our Terms & Conditions