MindChamps Academy AU Enrolment Application

APPLICATION FORM

DOMESTIC STUDENT
USI
Unique Student Identifier
FULL NAME

First NameMiddle NameFamily Name
GENDER:
DATE OF BIRTH

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
RESIDENTIAL ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
POSTAL ADDRESS
POSTAL ADDRESS (if different from Residential Address)

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
MOBILE

Area CodePhone Number
EMERGENCY CONTACT DETAILS / GUARDIAN OR PARENT
FULL NAME
RELATIONSHIP
TELEPHONE / MOBILE

Area CodePhone 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?
COURSE / QUALIFICATION OF INTEREST
CODE and TITLE
CODE and TITLE (old)
LOCATION

Other
LOCATION (old)
START DATE

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How did you hear about this course?

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?
The following information is required so MindChamps Academy can report statistics to the State and Federal Governments
SECONDARY EDUCATION
In which YEAR did you complete that school level?
Are you still attending secondary school?
REASON FOR STUDY
TERTIARY EDUCATION
EMPLOYMENT STATUS

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?
In which country were you born?

Other (please specify)
Main language spoken at home?
Are you an Australian Citizen?
Are you a Permanent Australian Resident?
Are you a New Zealand Citizen?
DISABILITY
Do you consider yourself to have a disability, impairment or long-term condition?
If YES please tick [ ✓ ] the relevant boxes

Other (please specify)
STUDENT'S/ TRAINEE’S DECLARATION

DECLARATION
- 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 on our website.
- I understand that, in compliance with the relevant Australian State/Territory laws and regulations, MindChamps Academy is required to provide statistical information about our Students and, in some cases, their personal information to the relevant Government Departments for administrative and research purposes.
- I declare that the information I have provided is true and correct, to the best of my knowledge. I have read and understood the contents, and I accept the responsibilities and obligations for this arrangement with MindChamps Academy.
Signature of Student
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
NOTE: For Students 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
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

APPLICATION FORM