MindChamps Academy AU Enrolment Application

APPLICATION FORM

DOMESTIC STUDENT
USI *
Unique Student Identifier
FULL NAME *

First Name Middle Name Family Name
GENDER: *

FEMALE MALE OTHER
DATE OF BIRTH *

Day Month Year
Date
RESIDENTIAL ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
POSTAL ADDRESS

Please tick if your postal address is same as above, or provide your postal address below.
POSTAL ADDRESS (if different from Residential Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMAIL (1) *
example@example.com
EMAIL (2)
example@example.com
TELEPHONE *

Area Code Phone Number
MOBILE *

Area Code Phone Number
EMERGENCY CONTACT DETAILS / GUARDIAN OR PARENT
FULL NAME *
RELATIONSHIP *
TELEPHONE / MOBILE *

Area Code Phone Number
EMAIL *
example@example.com
In the event of an emergency do you give MindChamps Academy permission to organize emergency transport and treatment (for example, ambulance if necessary) and agree to pay all costs associatedwith your emergency treatment/transport?

NO YES
COURSE / QUALIFICATION OF INTEREST
CODE and TITLE *
LOCATION *
START DATE *

Day Month Year
Date
How did you hear about this course? *

Previous Learner Friend / Relative Internet Newspaper Radio TV EXPO Facebook Other
Recognition of Prior Learning (RPL) / Direct Credit Transfer (CT) - if applicable
Do you wish to apply for RPL / CT for any of the units of competency offered by MindChamps Academy? *

NO YES
The following information is required so MindChamps Academy can report statistics (no names) to the State and Federal Governments
SECONDARY EDUCATION *

Year 12 or equivalent Year 11 or equivalent Year 10 or equivalent Year 9 or equivalent Year 8 or equivalent Never Attend School
In which YEAR did you complete that school level? *
Are you still attending secondary school? *

NO YES
REASON FOR STUDY *

To get a job To develop my existing business To start my own business To try for a different career To get a better job or promotion It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interest or self-development Other reasons
TERTIARY EDUCATION *

Bachelor degree or higher degree Advanced diploma or associate degree Diploma (or associate diploma) Certificate IV (or advanced certificate/technician) Certificate III (or trade certificate) Certificate II Certificate I Other education (including certificates or overseas qualification not listed above) None
EMPLOYMENT STATUS *

Full-time employee Part-time employee Self-employed – not employing others Self-employed – employing others Employed – unpaid worker in a family business Unemployed – Seeking full-time work Unemployed – Seeking part-time work Not employed – Not seeking employment Apprenticeship / Traineeship – (if applicable please provide employer name and contact details below)
LANGUAGE AND CULTURAL DIVERSITY
Are you of Aboriginal or Torres Strait Islander origin? *

No Yes, Aboriginal Yes, Torres Strait Islander
In which country were you born? *

Australia Other (please specify)
Main language spoken at home? *
Are you an Australian Citizen? *

No Yes
Are you a Permanent Australian Resident?

No Yes
Are you a New Zealand Citizen?

No Yes
DISABILITY
Do you consider yourself to have a disability, impairment or long-term condition? *

NO YES
If YES please tick [ ✓ ] the relevant boxes

Hearing/deaf Physical Intellectual Learning Mental illness Acquired brain impairment Vision Medical condition Other (please specify)
LEARNER / TRAINEE’S DECLARATION

DECLARATION
- I understand that there is a cooling-off period of fourteen (14) calendar days during which this application of enrolment can be withdrawn by all parties involved (RTO / Learner / Employer / Relevant Government Departments) with full refund of any fees paid up in advance, on the condition that I return all course materials, resources and other RTO property to MindChamps Academy in its original condition;
- I have read and understood the information set out in this application form, and by signing this application I agree to the terms and conditions relating to MindChamps Academy course fees, course requirements, policies and procedures on privacy, complaints, appeals, work health and safety, and the other conditions set out in the Student Handbook which is available for viewing our website.
- I understand that, in compliance with relevant Australian State/Territory law, MindChamps Academy is required to provide statistical information about its Learners and, in some cases, personal information to relevant Government Departments for administration and research purposes;
- I declare that the information I have provided is true and correct, to the best of my knowledge. I have read, understood, and I accept the responsibilities and obligations for this arrangement.
Learner Signature *

Clear
Date *

Day Month Year
Date
NOTE: For Learners under the age of 18, a parent or legal guardian must print their name and sign this form below
Full name of parent or legal guardian
Signature of parent or legal guardian

Clear
Date

Day Month Year
Date
Should be Empty:

APPLICATION FORM