Accredited Short Course Enrolment Form

1. COURSE INFORMATION Course NameInterpret and Apply Medical Terminology Appropriately (HLTENN040) - Accredited Short CourseAdminister and Monitor Medicines and Intravenous Therapy (HLTENN040) - Accredited Short CourseProvide Cardiopulmonary Resuscitation (HLTAID009) - Accredited Short CourseAssist with Basic Foot Care (HLTAHA030) - Accredited Short CourseProvide First Aid (HLTAID011) - Accredited Short CourseCertificate III Allied Health Assistance (HLT33015) - VETDSS Course

2. MODE OF DELIVERY Face to FaceBlendedWork Based

3. PERSONAL DETAILS 3. PERSONAL DETAILS

Title Title Mr. Mrs. Miss Other

Surname (Legal Family Name)

Given Name(s) Please write the name that you used when you applied for your Unique Student Identifier (USI), including any middle names. If you do not yet have a USI and want Mayfield Education to apply for a USI on your behalf, you must write your name, including any middle names, exactly as written in the identity document you choose to use for this purpose.

Gender Gender Male Female Indeterminate/Intersex/Unspecified

Date of Birth

4. ADDRESS DETAILS 4. ADDRESS DETAILS

Building / Property Name

Flat / Unit Number

Street Number

Street Name

Suburb

Post Code

Postal Address (if different from above)

5. CONTACT DETAILS 5. CONTACT DETAILS (Please tick preferred contact method – Email* or Mobile*) Email Mobile

Email

Alternate Email

Mobile

Work Phone

Home Phone

6. EMERGENCY CONTACT 6. EMERGENCY CONTACT

Name

Phone

Relationship

7. PREVIOUS QUALIFICATIONS 7. PREVIOUS QUALIFICATIONS Have you completed any of the qualification levels listed below: Yes (If yes, please select the qualification level below) No (If No, please go to Part 9)

- Bachelor’s degree or Higher Degree - Bachelor’s degree or Higher Degree Australian Australian Equivalent International

- Advanced Diploma or Associate Degree - Advanced Diploma or Associate Degree Australian Australian Equivalent International

- Diploma or Associate Diploma - Diploma or Associate Diploma Australian Australian Equivalent International

- Certificate IV or Advanced Certificate/Technician - Certificate IV or Advanced Certificate/Technician Australian Australian Equivalent International

- Certificate III or Trade Certificate - Certificate III or Trade Certificate Australian Australian Equivalent International

- Certificate II - Certificate II Australian Australian Equivalent International

- Certificate I - Certificate I Australian Australian Equivalent International

- Certificates other than listed above - Certificates other than listed above Australian Australian Equivalent International

Year Completed Please provide certified documents for the courses that you completed

Page Name

pageURL

8. LANGUAGE AND CULTURAL DIVERSITY 8. LANGUAGE AND CULTURAL DIVERSITY

Are you of Aboriginal or Torres Strait Islander origin Are you of Aboriginal or Torres Strait Islander origin No Yes, Aboriginal Yes, Torres Strait Islander Yes, Both

9. DISABILITY 9. DISABILITY

Do you consider yourself to have a disability, impairment, or long-term condition? Do you consider yourself to have a disability, impairment, or long-term condition? Yes (If yes, please indicate the areas of disability impairment or long-term condition below) No (If No, please go to Part 11))

Areas of disability impairment or long term condition Areas of disability impairment or long term condition Hearing/Deaf Acquired Brain Impairment Medical Condition Physical Mental Health Condition Learning Intellectual Vision Other

10. RESIDENTIAL STATUS 10. RESIDENTIAL STATUS

What is your current Australian residential status? What is your current Australian residential status? (Please tick one box only) Australian Citizen Holder of a Permanent Resident Visa of Australia New Zealand Citizen Other Visa type (please specify)

Please specify other visa type

11. STUDY REASON 11. STUDY REASON

Of the following categories, which best describes your main reason for undertaking this program/ traineeship / apprenticeship Of the following categories, which best describes your main reason for undertaking this program/ traineeship / apprenticeship To develop my existing business Skills for community/voluntary work To get better job or promotion To get into another program of study Personal Interest & Self-development To try for a different career I wanted extra skills for my job Requirement of my job To Start my own business To get a job Other reason

12. EMPLOYMENT 12. EMPLOYMENT

Current Employment Status Current Employment Status (Tick one box that best describes your current employment status) Full-Time Employee Part-Time Employee Self-Employed (Employing Others) Self-employed (Not Employing Others) Unemployed (Seeking Part-Time Work) Not employed (Not Seeking Work) Unemployed (Seeking Full-Time Work) Employed (Unpaid worker in a family business)

Current/Recent Occupation Current/Recent Occupation (Tick one box that best describes your current or recent occupation. If never employed, go to Question 15) Managers Professionals Technicians & Trade Workers Community & Personal Service Clerical & Administrative Workers Sales Workers Machinery Operators and Drivers Labourers Other

Current/Recent Industry Current/Recent Industry Agriculture, Forestry & Fishing Mining Manufacturing Electricity, Gas, Water & Waste Services Construction Wholesale Trade Retail Trade Accommodation & Food Services Transport, Postal & Warehousing Information Media & Telecommunication Financial and Insurance Services Rental, Hiring & Real Estate Services Professional, Scientific & Technical Services Administrative and Support Services Public Administration & Safety Education and Training Health Care & Social Assistance Arts & Recreation Services Other Services

13. USI 13. USI

Enter your Unique Student Identifier (USI) From 1 January 2015, we Mayfield Education can be prevented from issuing you with a nationally recognised VET qualification or statement of attainment when you complete your program if you do not have a Unique Student Identifier (USI). If you have not yet obtained a USI, you can apply for it directly https://www.usi.gov.au/ create-your-usi/ on a computer or mobile device. If you want Mayfield to create USI on your behalf, please contact the Admissions Department.

14. POLICIES & PROCEDURES 14. POLICIES & PROCEDURES INFORMATION: Refer to Mayfield Education’s policies and procedures which can be access through the Mayfield Education website: www.mayfield.edu.au - Fee Refund Policy and Procedure - Complaints and Appeals Policy and Procedure - Code of Conduct - Fees and Charges Policy and Procedure - Access and Equity Policy and Procedure - Recognition of Prior Learning - Course Credit Policy & Procedure - Qualification Issuing Policy and Procedure - Privacy Policy and Procedure