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RT0 20863 - F Bremner Pty.Ltd. (ABN 41 080 730 150) Trading as
Accredited First Aid Courses
Telephone: 03 9850 6665 or 03 9850 6699 Email:

STUDENT ENROLMENT FORM Version:1st June 2016

PLEASE TYPE OR WRITE CLEARLY. COMPLETE ALL QUESTIONS & INFORMATION

PLACE AN ‘X’ IN THE COURSE YOU ARE ATTENDING:

HLTAID003 (Level 2) HLTAID002 (Level 1) CPR HLTAID001

Anaphylaxis 22300VIC HLTAID004 Child Care/Education Setting Oxygen 22298VIC

Asthma 22282VIC EpiPen Annual Update VU21800

Enter your 10 Digit USI No

Date of Course: Venue:

Personal details ID Sighted [ ] (1) Enter your Legal Name as per your USI Identification:

FIRST NAME/S:

FAMILY NAME (surname):

Preferred Name:

(2) Date of Birth: 3. Sex (place an ‘X’) Male M Female F

Phone Number: Email Address:

(4) What is the address of your usual residence? Please provide the physical address (street number and name not post office box) where you usually reside rather than any temporary address at which you reside for training, work or other purposes before returning to your home.

s

House/Unit Number: Street Name:

Suburb: State: Post Code:

(5) What is your postal address? (if different from above):

How well do you speak English? Very well: Well: Not well: Not at all:

(9) Are you of Aboriginal or Torres Strait Islander origin? (For persons of both Aboriginal and Torres Strait Islander origin, mark both ‘Yes’ boxes)

No Yes, Aboriginal Yes, Torres Strait Islander

Disability Do you have a disability, allergies, impairment or long-term condition?

Yes (Please advise the office and the trainer should you require assistance) No

What Assistance is required:

Study reason

(18) Which of the following categories, BEST describes your main reason for undertaking this course?

(Place an ‘X’ in ONE box only)

To get a job 01 To develop my existing business 02

To start my own business 03 To try for a different career 04

To get a better job or promotion 05 It was a requirement of my job 06

I wanted extra skills for my job 07 To get into another course of study 08

For personal interest or self-development 09 Other reasons 10

If applicable: Company’s Name that is paying for this course:

CANDIDATES SIGNATURE:

2