2012 Australian Open Enrolment

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					SAS PRACTITIONER TRAINING 2012
AUSTRALIAN APPLICATION FORM
Australian Application Form
This form is to be completed by each practitioner applying to attend Secret Agent Society (SAS) Group Facilitator
Training. Please answer all questions and print clearly using BLOCK CAPITALS. Completed forms are to be
submitted with the Program Planning Questionnaire to the Training Coordinator at the Social Skills Training
Institute.

SECTION 1: Practitioner Details
Title (e.g. Mr/Ms/Dr):                                                          Date:         /      /

First name(s):

Surname:

Name to appear on certificate:




Organisation name:

Position within organisation:

Work postal address:

Town / Suburb:                                 State:                                    Postcode:

Billing address (if different from above):




Telephone number(s):                                                 Fax:

Work email address:

Alternate email address:




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SECTION 2: Qualifications and Experience
Relevant tertiary qualifications:




Briefly describe your experience working with children with Autism Spectrum Conditions (ASCs):




How many years experience do you have in this field?                              years


SECTION 3: Order Details

Please enter and total the costs that apply:
Please note: Each additional practitioner from an organisation who is trained within a 12-month period receives a 5% discount
on the training course and Facilitator Kit costs.

       Please indicate (tick) if the additional 5% practitioner discount applies

 1      Training course cost ($590/$560.50 with discount)                                                       $
        2 day training, morning tea, lunch, afternoon tea, ½ hour supervision support.

 2      Facilitator Kit cost ($328/$311.60 with discount)                                                       $
        To be purchased by all professionals to meet quality assurance requirements for program delivery.

 3      Session Resources Kit cost ($581)                                                                       $
        A minimum of one Session Resources Kit will need to be purchased for every four practitioners from an
        organisation who are being trained.

        TOTAL (1 + 2 + 3)                                                                                       $
        Please Note: All prices are introductory and inclusive of GST and postage & handling.




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 Please indicate below (tick) if you already own a copy of the SAS Computer Game or the SAS Challenger
 Board Game. If so, the cost of your Session Resources Kit will be adjusted accordingly to avoid resource
 duplication.

                          SAS Computer Game


                          SAS Challenger Board Game



SECTION 4: Training Course
Please indicate which practitioner training course you would like to attend by ticking the relevant box:

        City            Day / Date                     Time                  Venue/ Location                       Reg. Closes


       Brisbane           th     st
                        20 & 21 September              8:45 am – 4:30 pm     Social Skills Training Institute
                                                                                                                     th
                                                                                                                   30 August 2012
                        2012
                                                                             Head Office

                                                                             11 Market St

                                                                             Indooroopilly QLD 4068


       Perth              th     th
                        24 & 25 September              8:45 am – 4:30 pm     Trinity Conference Centre
                                                                                                                    rd
                                                                                                                   3 September 2012
                        2012
                                                                             230 Hampden Rd

                                                                             Crawley WA, 6009


       Melbourne          th     th
                        18 & 19 October 2012           8:45 am – 4:30 pm     Citigate Melbourne
                                                                                                                     th
                                                                                                                   27 September 2012

                                                                             270 Flingers St

                                                                             Melbourne VIC, 3000


       Sydney             th     th
                        25 & 26 October 2012           8:45 am – 4:30 pm     Punthill North Shore
                                                                                                                    th
                                                                                                                   4 October 2012

                                                                             472 Pacific Highway

                                                                             Lane Cove North NSW, 2066




Special dietary requirements (if any):

Number of practitioners from your organisation attending this training course:                                  practitioners

Please Note: Courses are offered conditional on a minimum number of practitioners registering to attend. Your training course will be
confirmed approximately three weeks prior to the scheduled date.




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SECTION 5: Payment Details
Please choose an option:

     Please invoice                Name:
                                    Organisation:
                                    Address:




                                    Purchase Order Number (if applicable):
     Electronic transfer           Electronic transfer details:
                                         Social Skills Training Institute
                                         Commonwealth Bank of Australia, Milton Branch
                                         BSB: 064 123 Account: 101 817 92

                                    Please email orders@sst-institute.net or fax 07 3878 5510 advising of payment and
                                    noting practitioner name(s).
     Pay by cheque                 Please enclose cheque, made out to the Social Skills Training Institute
     Pay by credit card            Card No:
                                    Visa/MasterCard:                                          Expiry date:            /
                                    Card Verification Code:

                                    Cardholder’s name:

                                    Signature*
                                    * if submitting by post

Amount (please transfer total from Section 2)                                                               AUD $
Price includes GST, postage & handling. Please note that your payment will not be processed until the training course has been confirmed,
approximately 3 weeks prior to the course.


SECTION 6: Additional/Follow Up Options

 Please tick the boxes below if you would like to order any additional resources or services at this stage. A
 staff member from the Social Skills Training Institute will contact you to discuss your chosen options
 further.

                       Family resources
                       Accreditation
                       Follow up support
If you require these resources or services at any time in the future, please contact us at sas@sst-institute.net.




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SECTION 7: Referral


 How did you find out about the Secret Agent Society Program?

               Speak Out (Speech Pathology Australia Magazine)
               InPsych (Australian Psychological Society Magazine)
               Internet/Website
               Word of mouth
               Other (please explain):



SECTION 8: Notes/Comments




Please send the completed Practitioner Training Application Form(s) and Program Planning
Questionnaire to the Training Coordinator at the Social Skills Training Institute via:

Mail     PO Box 1300, Milton, QLD 4064, Australia
Email    training@sst-institute.net
Fax      +61 7 3878 5510


These details are true and correct to the best of my knowledge:

Signed                                                                         Date     /        /




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