MindChamps Academy AU Enrolment Application

APPLICATION FORM

DOMESTIC STUDENT
USI*
Unique Student Identifier
FULL NAME*

First NameMiddle NameFamily Name
GENDER:*

FEMALEMALEOTHER
DATE OF BIRTH*

DayMonthYear
Date
RESIDENTIAL ADDRESS*

Street Address

Street Address Line 2

CityState / 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

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?

NOYES
COURSE / QUALIFICATION OF INTEREST
CODE and TITLE*

CHC30121 Certificate III in Early Childhood Education and CareCHC50121 Diploma of Early Childhood Education and Care
CODE and TITLE (old)
LOCATION*

LeichardtOther
LOCATION (old)
START DATE*

DayMonthYear
Date
How did you hear about this course?*

Previous LearnerFriend / RelativeInternetNewspaperRadioTVEXPOFacebookOther
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?*

NOYES
The following information is required so MindChamps Academy can report statistics to the State and Federal Governments
SECONDARY EDUCATION*

Year 12 or equivalentYear 11 or equivalentYear 10 or equivalentYear 9 or equivalentYear 8 or equivalentNever Attend School
In which YEAR did you complete that school level?*
Are you still attending secondary school?*

NOYES
REASON FOR STUDY*

To get a jobTo develop my existing businessTo start my own businessTo try for a different careerTo get a better job or promotionIt was a requirement of my jobI wanted extra skills for my jobTo get into another course of studyFor personal interest or self-developmentOther reasons
TERTIARY EDUCATION*

Bachelor degree or higher degreeAdvanced diploma or associate degreeDiploma (or associate diploma)Certificate IV (or advanced certificate/technician)Certificate III (or trade certificate)Certificate IICertificate IOther education (including certificates or overseas qualification not listed above)None
EMPLOYMENT STATUS*

Full-time employeePart-time employeeSelf-employed – not employing othersSelf-employed – employing othersEmployed – unpaid worker in a family businessUnemployed – Seeking full-time workUnemployed – Seeking part-time workNot employed – Not seeking employmentApprenticeship / Traineeship – (if applicable please provide employer name and contact details below)
LANGUAGE AND CULTURAL DIVERSITY
Are you of Aboriginal or Torres Strait Islander origin?*

NoYes, AboriginalYes, Torres Strait Islander
In which country were you born?*

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

NoYes
Are you a Permanent Australian Resident?

NoYes
Are you a New Zealand Citizen?

NoYes
DISABILITY
Do you consider yourself to have a disability, impairment or long-term condition?*

NOYES
If YES please tick [ ✓ ] the relevant boxes

Hearing/deafPhysicalIntellectualLearningMental illnessAcquired brain impairmentVisionMedical conditionOther (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*

Clear
Date*

DayMonthYear
Date
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

Clear
Date

DayMonthYear
Date
Should be Empty:

APPLICATION FORM