APPLICATION FOR ENROLMENT FORM 2015

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1 PROVIDE FIRST AID APPLICATION FOR ENROLMENT FORM 2015 State Enterprise Training (SET) act as the lead RTO to ensure all obligations regarding RTO registration standards are met including the issue of qualifications and statements of attainments that relate to the first aid units. MEDECS Australia have expertise in a wide range of health related skills and knowledge in both community based and health settings. They employ only Registered Nurses with the required national Trainer/Assessor competencies to deliver and assess the units. The first aid accreditation program, including delivery and assessment resources, have been designed and developed by MEDECS Australia in consultation with SET. Checklist before submitting your enrolment form Completed all sections Read & understood the cancellation policy Selected the relevant course by placing a tick in the box Please note that all enrolments close 48 hours before the allocated workshop you are to attend Medecs Australia Postal Address: P O Box 327 Glenorchy Tasmania Australia 7010 Phone: (03) Fax (03) Website: Medication Administration Enrolment Form 2015/ Page 1 of 6

2 Instructions Please fill in all sections clearly and carefully by writing in block letters. Information requested on this form is also for national database and tracking purposes and assists in qualification issuance. 1. PERSONAL DETAILS Title: (Please tick) Mr Ms Mrs Miss Other Family Name: Given Names: Residential Address: Postal Address: 2. PROVIDE FIRST AID 2015 COURSE DETAILS Post Code: Post Code: Phone Numbers: Home: Work: Mobile: Date of Birth: Town of Birth: Gender: M F Next of Kin & Relationship: Best phone No.: Please provide your Unique Student Identifier (USI) if you already have one or if not please provide either your Drivers License or Medicare Number. By ticking the Y box you agree to SET obtaining it for you: Y N If you have a Unique Student Identifier please provide: Medicare No: ( ) Exp date: Drivers Licence: OR (Please put the number you are on card in the brackets) This enrolment is for the units HLTAID003 Provide First Aid, and HLTAID001 Provide Cardiopulmonary Resuscitation. Please note all places are allocated on a first in basis. There is a maximum of 10 places in each course. If your preferences are not available you will be allocated a place in the next available course or assessment session. You will receive a confirmation notice to confirm your enrolment details. i) Please select the course below by placing a tick in the selection box of the course required and PROVIDE FIRST AID (2 DAY COURSE) $190 GST FREE SOUTH NORTH NORTH WEST Code Workshops FAS1 7 & 8 October FAN1 5 & 6 October FANW1 19 & 20 October FAS2 26 & 27 October FAN2 4 & 5 November FANW2 25 & 26 November FAS3 4 & 5 November FAN3 17 & 18 November FAS4 7 & 8 December FAN4 3 & 4 December FAS5 15 & 16 December FAN5 16 & 17 December FIRST AID REFRESHER (1 DAY COURSE) $ GST FREE SOUTH NORTH NORTH WEST Code Workshops FARS1 15 October FARN1 29 October FARNW1 21 October FARS2 9 November FARN2 18 November FARS3 2 December FARN3 10 December Medication Administration Enrolment Form 2015/ Page 2 of 6

3 3. EMPLOYMENT DETAILS Full-time employee Permanent part-time employee Casual employee Name of Employer: Address: Town/Suburb: Telephone: Workplace Supervisor: Supervisor Postcode: Fax: Phone: Credit Card Details (if self funded) Visa MasterCard Exp Date: / Card No: Cardholder Name: Cardholder Signature: 4. CANCELLATION POLICY Medecs cancellation If in the unlikely event any program is cancelled by State Enterprise Training then a full refund of all fees paid up until that point will be refunded. Participant cancellation Cancellation notice for all enrolments will be accepted up to 48 hours prior to the course commencement day. A cancellation fee of $35.00 will be charged in this instance. Should the enrolment be cancelled after this time full fees will be charged to the employer/individual. Once the first day of a course commences then all enrolled participants will be charged. There are no refunds after the commencement day of each course. A self-funded participant or service organisation can receive a credit note to attend a future course based on availability of places, only in the same calendar year. 5. 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 that school level? Medication Administration Enrolment Form 2015/ Page 3 of 6

4 Have you completed any of the following national qualifications? No Yes Please tick below Certificate I Diploma (or Associate Diploma) Certificate II Advanced Diploma or Associate Degree Certificate III (or trade certificate) Bachelor Degree or Higher Degree Certificate IV (or Advanced Certificate/Technician) National Qualifications other than the above Year(s) Completed: 6. LANGUAGE AND CULTURAL DIVERSITY Are you of aboriginal or Torres Strait Islander origin? No Aboriginal Torres Strait Islander (For persons of both Aboriginal AND Torres Strait Islander origin, mark both Yes boxes) Were you born in Australia? Yes No, please specify: Do you speak a language other than English at home? No, English only (Go to section 8) Yes, please specify: If yes, how well do you speak English? Very Well Well Not well Not at all 7. ADDITIONAL LEARNING NEEDS Do you consider that you have a disability, impairment or long-term condition that may impact your learning? (You may indicate more than one area) No (Go to section 8) Yes, please specify below: Vision Hearing Physical Medical Condition Other (please specify): Language, Literacy and Numeracy skills (LLN) The qualification or course you are enrolling in will require a foundation level of LLN skills. Please tick the box(es) below if you require additional assistance in any of these areas. If you are unsure please request a confidential LLN self-assessment form to complete. If further assistance is required we will contact you and provide details of a confidential training service. Not Applicable Language (English) Literacy (Ability to read or write) Numeracy (Ability to understand and apply number concepts) 8. CONSENT Personal information will be managed in accordance with the Personal Information Protection Act I understand that State Enterprise Training will not pass this information to any other party without my written permission. Medication Administration Enrolment Form 2015/ Page 4 of 6

5 9. TRAINING AGREEMENT The obligations of Medecs Australia / State Enterprise Training Medecs Australia is undertaking to deliver and assess you in the qualification or unit(s) outlined in section two of this application form. The cost and payment options for this qualification/unit are outlined in section three of this application. This information below outlines the services you are to be provided by Medecs Australia/State Enterprise Training. These include the following: Learning resources (retained by the learner Medecs Australia). An educator to provide you guidance and support. This person has the necessary regulatory competencies including vocational experience at least to the level being delivered and current industry skills Medecs Australia. A validated assessment process to ensure the qualification you are undertaking is aligned to the national qualification criteria outlined in the relevant national training package Medecs Australia. A record keeping process to ensure the accuracy and integrity of all records Medecs Australia/State Enterprise Training. A management system to ensure we are responsive to our client's needs State Enterprise Training. Your obligations By signing this enrolment form you are agreeing to undertake the unit(s) with Medecs Australia/State Enterprise Training as outlined in section two of this application. The success of this qualification or unit(s) will be determined by your engagement. Please make sure you understand the requirements of undertaking this qualification or unit(s) as detailed in the course outline. 10. COMMUNICATING INFORMATION Students may from time to time receive communication from Medecs/SET in the form of s, phone calls and/or SMS regarding their workshop schedules, postponements or changes, assessment activities, updated qualifications, promotions, and upcoming events. If you do not wish to receive this information please tick the box below: I do not wish to receive this communication I also authorise my employer as an authorised representative to confirm, and where applicable, supply my personal details as held by them in accordance to the organisation s privacy policy. 11. PRIVACY STATEMENT Personal information is collected solely for the purpose of operating as a Registered Training Organisation. We collect only personal information that is necessary for our organisation to meet its professional and legal obligations in accordance with our SET Australian Privacy Principles (APP) Policy. The purpose of this policy and procedure is to ensure that State Enterprise Training collects, uses appropriately, and protects all personal information provided from all stakeholders, and ensures that it complies with the Privacy Act and Privacy Amendment Act (Enhancing Privacy Protection) Act A copy of this policy is available at or please request a copy from SET Client Services Department. Phone or - Personal Information is collected directly from students or authorised representatives of their employer organisation when the State Enterprise Training Enrolment Form is completed. We may also collect personal information when you complete assessment activities, deal with us over the telephone or send us correspondence (including letters, s, faxes, social media, website enquiries and SMS). State Enterprise Training will take all reasonable steps to protect the personal information it holds from misuse and loss, and from unauthorised access, modification or disclosure. Medication Administration Enrolment Form 2015/ Page 5 of 6

6 State Enterprise Training as a registered RTO, is required to provide the Commonwealth government national training information data (AVETMISS) with student and training activity data which will include your information provided on the enrolment form. AVETMISS data (Australian Vocational Education and Training Management Information Statistical Standard) is a national standard for the collection and analysis of VET information throughout Australia. 12. DECLARATION I declare that I have been provided all the relevant information regarding the services to be provided by Medecs Australia/State Enterprise Training. I understand my rights and obligations in regards to this training agreement. I agree to enrolment in the short courses listed overleaf as per the schedules set out by Medecs and my employer. I understand that information contained in these forms may be provided to State and Commonwealth agencies and research organisations according to the Australian Privacy Principles and SET AAP privacy policy. I consent to that occurring. I certify that all details provided on these forms are correct. Signed: Date: 13. ENROLMENT SIGNATURE I have read and understood all details in this form and I certify that all information provided by me on this form is correct to the best of my knowledge. Applicant Signature: Date: Authorised Person s Name: Position: Authorised Person s Signature: Date: Medication Administration Enrolment Form 2015/ Page 6 of 6

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