TITLE (Ms / Mr / Miss / Mrs etc)  

FIRST NAME        SURNAME                

GENDER    PLEASE SELECT FEMALE MALE      

DATE OF BIRTH     DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / MM JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER / 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 YYYY  

COUNTRY OF BIRTH  

ADDRESS   

SUBURB               

POSTCODE   

PHONE NUMBERS:   HOME      WORK     

                                    MOBILE             FAX 

EMAIL  

(When submitted a copy of this form will be sent to this email address)

CONFIRM EMAIL   

BENEFIT NO: 

KOORIE/TORRES STRAIT ISLAND ORIGIN    PLEASE CHOOSE YES NO

MAIN LANGUAGE SPOKEN AT HOME  

SPOKEN ENGLISH LEVEL   PLEASE SELECT VERY WELL WELL NOT WELL NOT AT ALL

EMPLOYMENT STATUS    PLEASE SELECT FULL TIME PART TIME SELF EMPLOYED EMPLOYER FAMILY WORKER SEEKING EMPLOYMENT NOT SEEKING EMPLOYMENT RETIRED

Do you have any disability, impairment or long term condition that affects your enrolment    PLEASE SELECT YES NO

If YES do you require reasonable adjustments to assist your full participation in your course   PLEASE SELECT YES NO

Disabilities:

STILL AT SCHOOL  PLEASE SELECT YES NO

HIGHEST SCHOOL LEVEL COMPLETED     PLEASE SELECT DID NOT GO YR 8 OR BELOW YR 9 OR EQUIVALENT YR 10 OR EQUIVALENT YR 11 OR EQUIVALENT YR 12 OR EQUIVALENT  

IN WHICH YEAR DID YOU COMPLETE THAT LEVEL   

DOES THE MEMBER HAVE ANY PRIOR EDUCATION  PLEASE SELECT YES NO

IF SO AT WHAT LEVEL  PLEASE SELECT BACHELOR DEGREE OR HIGHER ADVANCED DIPLOMA OR ASSOCIATE DEGREE DIPLOMA CERTIFICATE IV CERTIFICATE III CERTIFICATE II CERTIFICATE I MISCELLANEOUS

NAME

RELATIONSHIP  

PHONE NUMBER  

DOCTOR'S NAME  

DOCTOR'S PHONE NUMBER  

Concessions apply to SOME classes if you hold one of the following cards   SELECT IF RELEVANT Centrelink Health Care Centrelink Pension Concession Card Seniors Card Veteran's Gold Card    CARD NO:

(To receive a concession on your class, your card needs to be sighted by office staff)

Name of Class     

 DAY    PLEASE SELECT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY         TERM    PLEASE SELECT TERM 1 TERM 2 TERM 3 TERM 4          COST   

This form will automatically be stamped with today's date when submitted.    

 A SIGNATURE WILL BE REQUIRED WHEN YOU NEXT ATTEND THE OFFICE

How did you hear about the Waverley Community Learning Centre?

PLEASE SELECT BROCHURE LOCAL PAPER INTERNET WORD OF MOUTH OTHER   If 'OTHER' please specify