Nationally Recognised Subsidised Training Application Form

Certificate IV in Mental Health

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Personal Details

Title

First Name:

Surname:

Preferred Name:

Date of Birth

Gender

Female

Male

E-mail Address

Mobile Number

Phone Number

Please upload a colour copy of your Drivers Licence or 18+ Card

Note: A Copy of both sdes of the Driver License will be required if you have a change off address label affixed

Unique Student Identifier Number (USI)

If you are a new or continuing student undertaking nationally recognised training, you need a USI in order to receive your qualification or statement of attainment. Your USI will look something like this: 3AW88YH9U5

You can retrieve or create your USI by visiting https://www.usi.gov.au/

Unique Student Identifier (USI):

Address

What is the address of your usual residence?

Please provide the physical address (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.

Address 1:

Address 2

Address - Home - Unit/Flat Number

Address - Home - Street/Lot Number

Address - Home - Street Name

Suburb

State

Post Code

Country

Do you have a different postal address?

Yes

Address - Postal - Unit/Flat Number

Address - Postal - Street/Lot Number

Address - Postal - Street Name

Address - Postal - Suburb

Address - Postal - Post Code

Address - Postal - State

Emergency Contact:

Full Name:

Relationship:

Contact Number:

Language & Cultural Diversity

In which country were you born?

What language do you speak at home?

Are you of Aboriginal or Torres Strait Islander origin?

What is your residency status?

Australian citizen

New Zealand citizen living in Australia

Visa holder on a pathway to permanent Australian residence

Holder of identified visa that grants the rights to work in Australia

Permanent Australian Resident

Please specify your Visa type:

Personal Circumstance & Disability

Do you consider yourself to have a disability, impairment or long-term condition?

Not Stated

Yes

If you indicated the presence of a disability, impairment or long-term condition, please specify:

Is there anything about your personal circumstance that may impact your studies?

For example: Specific disability requirements, limited or no internet access, assistance with language, literacy or numeracy etc.

Schooling & Previous Qualifications

Are you still attending secondary school?

Not Stated

Yes

What is your highest COMPLETED school level?

In which YEAR did you complete that school level?

Have you SUCCESSFULLY completed any of the following qualifications in Australia? If YES, then tick ANY applicable boxes:

Entry Requirements: If your course has specific entry requirements then please upload any evidence of relevant qualifications or certificates that you have obtained - alternatively please upload your CV here :

Credit Transfer

Would you like to apply for Credit Transfer/s?

Credit transfers will only be awarded for authenticated and eligible qualifications/transcripts as outlined in our Student Handbook.

Yes

Please upload any evidence of relevant qualifications or certificates that you have obtained for Credit Transfer/s:

Recognised Prior Learning

Do you wish to apply for Recognised Prior Learning?

An RPL interview will be conducted by your Trainer Assessor after enrolment to determine eligibility. Please note, RPL is not necessarily a quick process. A student is required to collate and coordinate evidence to show they have sufficient, valid and current knowledge and skills equivalent to the qualification they are enrolled in.

Yes

Please upload any evidence of relevant qualifications or certificates that you have obtained for Recognised Prior Learning:

Payment Option, Employment & Reason For Study

What is your preferred payment option?

I would like to pay for the Full Fee

I would like to go on a Fortnightly Payment Plan

My workplace is paying

What is your job title?

What is the name of your workplace to be invoiced?

Who is your workplace contact person?

What is their contact number?

Workplace postal address:

What is your workplace email address?

Please upload your purchase order / workplace authorisation document here:

Of the following categories, which BEST describes your current employment status?

If you are Employed, what is your Employer Postcode:

If you are Employed, what is your Employer Suburb

Of the following categories, which BEST describes your main reason for undertaking this course/traineeship/apprenticeship?

Please specify if you are on any Concession:

Concession Expiry Date

Other Service Providers

Are you registered with an Employment Service Provider?

Yes

What is the name of your Employment Service Provider?

What is your Employer Service Providers email address?

What is your Job Seeker ID number?

Privacy Statement and Student Declaration

By ticking the below listed statements and signing this application, I declare:

Privacy Consent Statement

I declare that the information I have provided to the best of my knowledge is true and correct.

I have accessed, read and understood the student handbook, schedule of fees and all course related information on the Australian Institute of Social Relations website.

I understand that the Australian Institute of Social Relations is required to submit data sourced from this enrolment form to the national VET administrative collection as a regulatory reporting requirement. The information contained on my enrolment form may be used by the Australian Institute of Social Relations for the following third parties for administrative, regulatory and/or research purposes:

- School, if I am a secondary student undertaking VET, including a school based apprenticeship or traineeship.

- Employer, if I am enrolled in training paid by my employer.

- Government departments and authorised agencies.

- Researchers.

I wish to participate in an activity funded by the Skills and Employment Division in the Department of Innovation and Skills.

I accept that the Minister for Employment, Higher Education and Skills (Minister) will allocate to me a Participant Number, to be used to record my participation in, and the results of, activities funded by the Skills and Employment Division in the Department of Industry and Skills.

I accept that the assessment as to whether I am eligible to participate in any specific activity funded by the Skills and Employment Division in the Department of Innovation and Skills will be undertaken by a service provider who has a contract with the Minister for the delivery of the activity.

I consent to the Minister, its employees, agents and contractors collecting from the service provider my results for all courses in which I have been enrolled, and using this information for the purpose of determining whether I am eligible to enrol in an activity funded by the Skills and Employment Division in the Department of Innovation and Skills. I consent to the Minister, its employees, agents and contractors using this information for the Department of Innovation and Skills performance measurement and reporting activities.

I consent to the Minister, its employees, agents and contractors collecting and using any student identifier (as that term is defined in the Student Identifiers Act 2014) assigned to or relating to me and using that student identifier to obtain transcripts and other information relating to me and using this information to determine my eligibility for an activity funded by the Skills and Employment Division in the Department of Innovation and Skills and to record and track my progress through the activities funded by the Skills and Employment Division in the Department of Innovation and Skills.

I accept and agree that the Minister, its employees, agents and contractors will be in receipt of my Personal Information and that they may be required to share my personal information with:

Yes, I agree

Student Full Name

Digital Signature

Draw It
Clear

Are you under 18 years of age?

Yes, I am

Please provide the full name of the Guardian:

Signature of Guardian

Draw It
Clear

Subscribe me to the Australian Institute of Social Relations e-newsletter to receive information on upcoming courses and promotions

How did you hear about us?

Brochure, Poster or Postcard

Email Newsletter

Expo or Community Event

Social Media (eg Facebook, Twitter, Youtube etc)

Traditional Media (Newspaper, Television, Radio, Magazine)

Word of Mouth

Website

Industry Conference or Exhibition

This course is currently not open for enrolments