Enrolment Application Form 2012 by u2iYRnM

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Study Enrolment Application
ALL SECTIONS MUST BE COMPLETED
Section 1:         STUDENT DETAILS

Title:     Mr          Mrs           Miss         Ms

Surname: _____________________________                 Given Names: ____________________________

Number/Street: ____________________________                Suburb: ______________________________

Post Code: _____________           Date of Birth:_________________       Place of Birth:_______________

Home Phone:___________________________                 Your Mobile Number:_______________________

Email address:______________________________________________________________________


EMERGENCY CONTACT

Name:_________________________________ Contact Number:___________________________


Section 2:         WHICH COURSE ARE YOU APPLYING FOR?

    Course Name                                                                    Course     Tick
                                                                                   Code
    Certificate III Aboriginal and/or Torres Strait Islander Primary Health Care   HLT33207

    Certificate IV Aboriginal and/or Torres Strait Islander Primary Health Care    HLT43907
    (Practice)

    Diploma Aboriginal and/or Torres Strait Islander Primary Health Care           HLT52107
    (Practice)

    Certificate IV Mental Health                                                   CHC40508

    Diploma Community Services (Mental Health)                                     CHC50308

    Diploma Nursing (Enrolled/Division2 Nursing)                                   HLT51607

    Diploma Management                                                             BSB51107

    Certificate III Health Services Assistant                                      HLT32507




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Version 2            Application Form 2012; Marr Mooditj Training Inc.  Date: Jan’12
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 Enrolment Requirements
 You must be of Aboriginal and/or Torres Strait Islander descent and older than 17 years
 Agree to complete all work placements arranged as per the training requirements
 Agree to a payment plan with Marr Mooditj Training Inc, to pay all fees/costs
 Living in Western Australia
 To receive away from base allowances – must provide a statutory declaration of address
 If required, provide a Police Clearance and/or Working With Children Check and/or Medical
 Screening (Forms available from Post Office)



Section 3:       GENERAL STUDENT INFORMATION

Is this the first time you have enrolled at Marr Mooditj Training Inc?     Yes:            No:

If ‘No’ then please state the course/s you previously enrolled in:

__________________________________________________________________________________

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What language do you speak at home?             English:
                                                Other Language:

How well do you speak English?

 Very Well
 Well
 Not Very Well
 Not at All


How well do you read and write English?

 Very Well
 Well
 Not Very Well
 Not at All




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Version 2            Application Form 2012; Marr Mooditj Training Inc.  Date: Jan’12
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Some courses require a sound level of maths - please indicate how good you are in maths:

 Very Good
 Good                                     Are you still attending Secondary School? Yes        No
 Not Very Good
 Never Done Maths


Please indicate which year/level you left school:

 Year 12 or equivalent                     In what year did you leave school (e.g. 1998)? _________
 Year 11 or equivalent
 Year 10 or equivalent
 Year 9 or equivalent
 Year 8 or below
 Never attended school


Please indicate your highest current qualification:

 Bachelor / Degree
 Advanced Diploma
 Diploma or Associate
 Certificate IV
 Certificate III or (Trade)
 Certificate II
 Certificate I
 Other:


Please indicate if you have a disability, impairment or long term condition:

 Hearing/Deaf                                 Medical Condition
 Physical                                     Vision
 Intellectual                                 Other
 Learning
 Mental Illness
 Acquired Brain Impairment




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Version 2            Application Form 2012; Marr Mooditj Training Inc.  Date: Jan’12
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What best describes your employment?

Full time
Part time
Self employed
Employer
Unemployed seeking full time employment
Unemployed seeking part time employment


If you are working, please provide your employer details:

Employer:          ____________________________
Address:           __________________________________________________________________
                   __________________________________________________________________
Phone:             _____________________________         Fax: ______________________________
What is your position? ____________________________________________________________

Why do you want to do the course? (You can indicate more than one box)

To get a job
To develop my own business
To try a different career
To get a promotion
It is part of my job requirements
I want extra skills
For personal interest or Self development
Other reasons


Where did you hear about Marr Mooditj Training? (Please tick)

Internet                                    Marketing Materials
Advertisements                              Other
Family & Friends
Place of Employment
Radio
I hereby declare that all of the information provided in this application is accurate and true.

_________________________________________                         _______________________
       Applicant Signature                                               Date
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Version 2            Application Form 2012; Marr Mooditj Training Inc.  Date: Jan’12
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Section 4:     SUBMIT YOUR APPLICATION TO

MARR MOODITJ TRAINING INC
PO BOX 1030, BENTLEY DELIVERY CENTRE, WA 6983
Phone: (08) 9351 9344       Fax: (08) 9350 6830

www.marrmooditj.com.au or Email: reception1@marrmooditj.com.au

Section 5:     APPLICATION PROCESS

1. A letter of acknowledgement will be send by mail to you within 2 working days of receipt
   of your application. If you have not received notice please telephone Marr Mooditj
   Training.
2. Marr Mooditj Training’ Student Services Area will process your application within 5
   working days and upon successful application will send you a confirmation of your
   enrolment.
3. If there are no available places, then the Student Services staff may recommend another
   study course of your interest.
4. Students may be advised to complete LL&N training at Marr Mooditj Training prior to
   enrolment in the course of your choice.

Section 6:     OFFICE USE ONLY

Staff member who received the application:    Name                              Date

Date acknowledgement letter send to applicant:

Application Approved            Application not approved

Reason for not approved: ____________________________________________________________

Student is accepted for which course? __________________________________________________

Will student be requiring travel & accommodation? Yes:          No:

Has the Travel & Accommodation Officer been informed? Yes:             No:

Name and Signature of staff member who send the confirmation of enrolment letter to student.



Name:_________________________ Signature: ___________________ Date: _______________




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Version 2            Application Form 2012; Marr Mooditj Training Inc.  Date: Jan’12

								
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