STUDENT ENROLMENT FORM STUDENT ENROLMENT FORM Information collected is within the guidelines of the Privacy Principles contained in the Privacy Act 2004 and will be used solely for CRANAplus activities. Complete ALL fields and return Form to: Email: admin6@crana.org.au Fax: (08) 8408 8222 Post: Po Box 127, Prospect SA 5082 UNIQUE STUDENT IDENTIFIER (USI) ST PLEASE NOTE: NEW GOVERNMENT LEGISLATION APPLYING FROM 1 JANUARY 2015 REQUIRES ALL STUDENTS UNDERTAKING NATIONALLY RECOGNISED TRAINING TO CREATE AND PROVIDE A USI NUMBER BEFORE CERTIFICATES FOR THE COURSE CAN BE ISSUED. CREATE YOUR USI AND FIND MORE INFORMATION AT USI.GOV.AU USI NUMBER: (MUST BE 10 DIGITS LONG) ** YOUR REGISTRATION CANNOT BE ACCEPTED UNTIL A VALID USI NUMBER IS RECEIVED** COURSE DETAILS COURSE TYPE (MEC, AREC, ALS, PEC, ATSI) COURSE DATES COURSE LOCATION APPLICANT PERSONAL INFORMATION TITLE: DR q MR q MRS q MISS q MS q FAMILY NAME: GIVEN NAME(S): DATE OF BIRTH: PREFERRED NAME: GENDE MALE q R: FEMALE q HOME EMAIL: E MERGENCY EMERGENCY CONTACT NAME: CONTACT PHONE NO. DO YOU HAVE ANY DIETARY DO YOU HAVE ANY HOME EMAIL: RESTRICTIONS? ALLERGIES? Given the remote location of many of our courses, we are sometimes restricted to Vegetarian and Gluten Free dietary options. While we always supply fresh food and fruit, particular foods PHONE NUMBER: may not be easily accessed in remote areas. Should you have quite specific restrictions we encourage you to bring some basics and then pick and choose from the fresh food offered on the day. You should also inform us of any allergies you may have so we can advise the caterer and be aware of the situation. Any queries to the course Coordinator. POSTAL ADDRESS DETAILS (WHERE ANY PHYSICAL COURSE MATERIALS WILL BE SENT) BUILDING/PROPERTY NAME: FLAT/UNIT NUMBER: STREET NUMBER: STREET NAME: PO BOX: SUBURB STATE: POSTCODE RESIDENTIAL ADDRESS -‐ IF DIFFERENT FROM ABOVE ADDRESS: ADDRESS: SUBURB: DO YOU WISH TO APPLY FOR? (PLEASE REFER TO STUDENT HANDBOOK FOR FURTHER INFORMATION ON THE PROCEDURES FOR APPLICATION FOR RPL OR CT) STATE: POSTCODE PRIOR RECOGNITION & CREDIT TRANSFER RECOGNITION OF PRIOR LEARNING (RPL) CREDIT TRANSFER (CT) q YES q NO q YES q NO ©CRANAplus Inc. RTO Number: 40719 Version 2.3 Student Enrolment Form – RTO FM021_13 IF YES, HAS AN APPLICATION/INFORMATION FORM BEEN PROVIDED TO YOU? q YES q NO 1 of 4 Created: 08/10/2013 Last Modified: 26/03/2015 Revision: 01/12/2015 STUDENT ENROLMENT FORM YOUR CURRENT DISCIPLINE (TICK MORE THAN ONE IF REQUIRED) ENROLLED NURSE q REGISTERED NURSE q DIRECT ENTRY MIDWIFE q REGISTERED NURSE & MIDWIFE q NURSE PRACTITIONER q ATSI HEALTH PRACTITIONER / WORKER q ORAL HEALTH PROFESSIONAL q UNDER-‐GRAD STUDENT q ALLIED HEALTH PROFESSIONAL q OTHER (PLEASE SPECIFY) q MEDICAL OFFICER (DOCTOR/MD/GP) q RACGP NUMBER: ACRRM NUMBER: WORKPLACE TYPE REMOTE PRIMARY HEALTH CARE q REMOTE INPATIENT CARE q RURAL PRIMARY HEALTH CARE q RURAL INPATIENT CARE q REGIONAL HEALTH SERVICE q URBAN HEALTH SERVICE q UNIVERSITY / EDUCATION q INTERNATIONAL DEVELOPMENT q ISOLATED INDUSTRY (MINING, CORRECTIONS, DEFENSE, TOURISM, SCHOOL) q AEROMEDICAL / TRANSPORT q OTHER (PLEASE SPECIFY) q WORKPLACE LOCATION -‐ WHERE DO YOU WORK? TOWN: STATE: BENEFICIARIES – WHERE DO YOU BELIEVE A MAJORITY OF BENEFICIARIES OF YOUR WORK RESIDE? REMOTE q RURAL q REGIONAL q URBAN q ADDITIONAL INFORMATION (INFORMATION IS USED FOR STATISTICAL REPORTING AS REQUIRED BY ACCREDITATION BODY) The Department of Industry collects this information for the purpose of auditing participation and the monitoring and reporting of training outcomes. The information you provide may be accessed by officers of Government departments and by the National Centre for Vocational Education Research (NCVER) for the above purposes. 1. In which country were you born? q Australia q Other (Please specify) …………………………………………… 2. Do you speak a language other than English at q No, English only home? q Yes, other (Please specify) ……………………………………… (If more than one language is spoken, indicate the most often used) 3. How well do you speak English? q Very Well 4. Are you of Aboriginal or Torres Strait Islander origin? q Well q Not Well q Not At All q Neither q Yes, Aboriginal q Yes, Torres Strait Islander q Yes, Both Aboriginal & Torres Strait Islander 5. Do you consider yourself to have a disability, impairment or long-‐term condition? q No (You may indicate more than one area) q Yes, Hearing/Deaf ©CRANAplus Inc. RTO Number: 40719 Version 2.3 Student Enrolment Form – RTO FM021_13 q Yes, Physical q Yes, Intellectual q Yes, Learning q Yes, Mental Illness q Yes, Acquired Brain Illness q Yes, Vision q Yes, Other (please specify __________________) 2 of 4 Created: 08/10/2013 Last Modified: 26/03/2015 Revision: 01/12/2015 STUDENT ENROLMENT FORM 6. What is your highest COMPLETED school level? (Tick one box only) q Completed year 12 q Completed year 11 q Completed year 10 or equivalent q Completed year 9 or equivalent q Completed year 8 or lower q Did not go to school 7. In which YEAR did you complete that school level? 8. Are you still attending secondary school? q Yes q No 9. Of the following categories, which BEST describes your current employment status? q Full-‐time Employee (Tick ONE box only) q Part-‐time Employee q Self employed – Not Employing Others q Employer q Employed – Unpaid Worker in a Family Business q Unemployed – Seeking Full-‐time Work q Unemployed – Seeking Part-‐time Work q Not Employed – Not Seeking Employment 10. Of the following categories, which BEST describes your main reason for undertaking this q To get a job course/traineeship? q To develop my existing business (Tick ONE box only) q To start my own business 11. What is your highest Qualification? q To try a different career q To get a better job or promotion q It was a requirement of my job q I wanted extra skills for my job q To get into another course of study q For personal interest or Self-‐development q Other reasons q Certificate 1 2 3 or 4 – specify _________ q Diploma (or hospital trained EN) q Bachelor degree (or hospital trained RN) q Graduate certificate/diploma q Masters q Doctorate ©CRANAplus Inc. RTO Number: 40719 Version 2.3 Student Enrolment Form – RTO FM021_13 3 of 4 Created: 08/10/2013 Last Modified: 26/03/2015 Revision: 01/12/2015 STUDENT ENROLMENT FORM PAYMENT DETAILS cOURSE TYPE MEMBER PRICE NON MEMBER PRICE $1050 $1100 MATERNITY EMERGENCY CARE (MEC) $760 $810 PAEDIATRIC EMERGENCY CARE (PEC) ADVANCED REMOTE EMERGENCY CARE (AREC) $1050 $1100 ADVANCED LIFE SUPPORT ONE DAY (ALS) – ALL MODULES $460 $460 ADVANCED LIFE SUPPORT ONE DAY (ALS) – RECERTIFICATION MODULES ONLY $360 $360 ABORIGINAL AND TORRES STRAIT ISLANDER (ATSI) MATERNITY EMERGENCY CARE $600 $650 q YES, I WOULD ALSO LIKE TO BECOME A MEMBER OF CRANAPLUS AND TAKE THE COURSE MEMBER RATE (MEMBERSHIP IS $150 PER YEAR) AS PART OF THE MEMBERSHIP, I WOULD LIKE TO RECEIVE MY COPY OF THE Australian Journal of Rural Health BY POST q BY EMAIL q The Refund policy can be found on our website: In event of notification of a cancellation 21 or less calendar days before the course commencement date: • Student fees paid will not be refunded or allocated to another course (no offer to transfer). • Access to any associated online modules will be terminated at the point of notification. AUTHORISATION & DECLARATION I (NAME): ______________________________________________________________ î authorise CRANAplus to collect, store and use my personal information within the limitations of the Privacy Principles contained in the Privacy Act 1988. î authorise CRANAplus to make relevant enquiries where necessary and in accordance with legislation regarding my academic qualifications and any work experience related to my application for undertaking a course of study. î understand that my information will only be released to third parties in accordance with legislation: State/Territory Government and Commonwealth agencies responsible and/or involved in training and education, including policy, funding, monitoring and/or compliance. î understand that I may at any time revoke my authorisation for CRANAplus to release my information to third parties by notifying CRANAplus and that my ability to revoke cannot be retrospective. î hereby consent to the collection and use of my personal information as outlined above. î agree with the Terms & Conditions (https://crana.org.au/education/refund-‐policy/) î am aware of the Student Handbook (https://crana.org.au/education/course-‐participant-‐information/student-‐handbook/) I declare that the information I have provided is, to the best of my knowledge, true and accurate. ________________________________________________________ Signature of Applicant _____________________________________ Date PAYMENT OPTIONS CREDIT CARD: For compliance and privacy we cannot accept written details and ask that you call our Adelaide office on (08) 8408 8203. PURCHASE ORDER: If your Workplace is paying, you should attach an accompanying Purchase Order with this completed form. EFT PAYMENTS: Account Name: CRANAplus Incorporated, BSB: 035-‐303, Account No. 315 552 (Ref Surname and Course type) CHEQUE/MONEY ORDER: Mail your cheque/money order to: PO Box 7410, CAIRNS QLD 4870 Your place on this Course is not guaranteed until the payment is complete and if no contact is made within 2 business days you risk forfeiting your place. * If you are participating in a Privately run Course, simply return this Form, as no payment details are required. ©CRANAplus Inc. RTO Number: 40719 Version 2.3 Student Enrolment Form – RTO FM021_13 4 of 4 Created: 08/10/2013 Last Modified: 26/03/2015 Revision: 01/12/2015