INSTRUCTIONS

Please:

  1. Print clearly
  2. Check that you have completedall sections of the form
  3. Obtain your USI before returning this form to Response Services Employment & Training
/
  1. Sign the declaration on the last page
  2. Attach copy of your identification
  3. Email completed and signed form and identification to:

Full Legal Name / Usual Residential Address
Title:
Mr Ms Mrs Other: / Number & Street:
Family Name: / Suburb/Town:State:Postcode:
Given Names: / Postal Address (Street/PO Box):
Preferred Name: / Former Surname: / Postal Suburb/Town:State:Postcode:
Unique Student Identifier (USI) (must have 10 characters) / Please provide identificationused for USI application
Drivers Licence Passport Birth Certificate other
Employer Name / Invoice to be sent to:
N/A
Gender / Date of Birth / Are you registered with a Job Services Provider?
No Yes specify branch
Are you receiving a Government Benefit? Yes No
Male: Female: / /
Contact Details / Language & Cultural Diversity
Tel (Home): ()
(Work): ()
(Mobile):
Email: / Are you of Aboriginal or Torres Strait Islander Origin?
No Yes, Aboriginal Yes, Torres Strait Islander
In which country were you born?
Australia
Other - please specify
Do you speak a language other than English at home?
No Yes please specify
How well do you speak English?
Very Well Well Not Well Not at all
Do you require assistance with language,
literacy or numeracy?Yes No
Education
What is your highest COMPLETED school level?
Year 12 Year 11 Year 10 Year 9
Year 8 or below Never attended school
In which YEAR did you complete that school level?
e.g. 1995:
Are you still attending secondary school?Yes No
Previous Qualifications Achieved / Citizenship (Tick one box)
Have you successfully completed any qualifications?
No Yes if yes, please specify below:
Bachelor Degree or Higher Degree
Advanced Diploma or Associate Degree
Diploma (or Associate Diploma)
Certificate IV (or Advanced Certificate/Technician)
Certificate III (or Trade Certificate)
Certificate II
Certificate I
Certificates other than the above / Australian citizen New Zealand citizen
Australian resident Temporary resident
Other - Specify
Employment
Of the following categories which best describes your current employment status? (tick ONE box only)
Full time employee (more than 30hrs per week)
Part time employee (less than 30hrs per week)
Self employed (no employees)
Employer
Unemployed (seeking full time work)
Unemployed (seeking part time work)
Employed (unpaid worker in a family business)
Not employed (not seeking work)
Disability
Do you have a disability, impairment or long-term condition?Yes No
If yes, please indicate area:
Acquired Brain Impairment Hearing/Deaf
IntellectualLearning Medical Condition
Mental Illness Physical Vision Other
Do you require special assistance because of this disability?Yes No
If yes, please specify
RPL/RCC
Do you wish to apply for Recognition for
Prior Learning / Direct Credit?Yes No

RTO ID 90278 Head Office: 63 Regent Street, New Lambton PO Box 3150 Merewether NSW 2291

Tel: 02 4940 5000 Email: Web: ABN 65 063 839 403

Course Details
Qualification code & Name:
CHC33015 Certificate III in Individual Support / Delivery Site:
Bayview NT 0820
Project #: 1705-270 / Commencement Date: / Completion Date: 5/3/18
Fees / Exemptions
Course Cost: $ Funded
Admin Fee: $ Nil / Have Admin fees been charged? N/A
If No, was proof of exemption sighted? N/A
Refund / Cancellation Policy
A fee refund, is given if the client cancels before commencement of the course.
In the unlikely event of course cancellation by Response a full fee refund is made to clients.
After commencement of the course, fees are non-refundable except at the discretion of the Manager.
Study Reason
Which BEST describes your main reason for undertaking this course / traineeship / apprenticeship? (Tick ONE box only)
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 or self-development Other reasons
Declaration
I, (print name) apply for admission to Response Services Employment & Training, and declare that:
  1. I must comply with the rules of Response Services Employment & Training
  2. I have read, understand and agree to all the Terms and Conditions outlined in the Participants’ Handbook
  3. I understand that my personal details will be collected for the purpose of student records required by training legislation and will not be sold to any party. These details will be also collected by state and federal government bodies, for the planning of national training initiatives. I can access my records by written request
  4. I must provide the same identification used when applying for my Unique Student Identifier.
  5. I authorise Response Services Employment & Training to verify my Unique Student Identifier (USI)
  6. I authoriseResponse Services Employment & Training to locate my Unique Student Identifier (USI)
  7. The information I have provided is true and correct to the best of my knowledge
...../….../20...... /....…/20….....
Participant’s signatureDateResponse Representative’s signatureDate
Units of Competence included in this course:
BUSCUS301 Deliver and monitor a service to customers
CHCCCS011 Meet personal support needs
CHCCCS015 Provide individualised support
CHCCCS023 Support independence and well being
CHCCOM005 Communicate and work in health or community services
CHCDIS001 Contribute to ongoing skills development using a strengths-based approach
CHCDIS002 Follow established person-centred behaviour supports
CHCDIS003 Support community participation and social inclusion
CHCDIS007 Facilitate the empowerment of people with disability
CHCDIV001 Work with diverse people
CHCLEG001 Work legally and ethically
HLTAAP001 Recognise healthy body systems
HLTWHS002 Follow safe work practices for direct client care

Version 15

RTO ID 90278 Head Office: 63 Regent Street, New Lambton PO Box 3150 Merewether NSW 2291

Tel: 02 4940 5000 Email: Web: ABN 65 063 839 403