Fee for Service Enrolment Form Step 1 of 5 20% Course name*Certificate III in Individual SupportCertificate IV in Ageing SupportCertificate IV in DisabilityCertificate IV in Mental HealthCertificate IV in Mental Health Peer WorkCertificate III in Allied Health AssistanceCertificate IV in Allied Health AssistanceProvide First AidDelivery Method*Classroom (Face to face)OnlinePlease indicate your location* Name* First Middle Last Date of birth* DD slash MM slash YYYY Town / City of birth* Gender* Male Female Other Home phoneWork phoneMobile*Email* Alternative email address Emergency contact name* Relationship* Mobile*How did you hear about this course?*GoogleFacebookEventReferralRadioOutdoor BillboardIndoor BillboardTelevisionbreakthru flyerJSAEmailOtherPlease specify:* What is the address of your usual residence? Please provide the physical address (street number and name NOT post-office box) where you usually reside rather than any temporary address at which you reside for training, work or other purposes before returning to your home. If you are from a rural area use the address from your state or territory’s rural property addressing’ or ‘numbering’ system as your residential street address. Building/property name is the official place name or common usage name for an address site, including the name of a building, Aboriginal community, homestead, building complex, agricultural property, park or unbounded address site.Building /property name Flat / unit details Street or lot number* Street name* Suburb, locality or town* State / territory* Postcode*What is your postal address (if different from above)?Building /property name Flat / unit details Street or lot number Street name Postal delivery information Suburb, locality or town State / territory Postcode Australian Residency Status* Australian citizen Permanent resident visa Humanitarian Visa New Zealand citizen Temporary visa Do you hold or are enrolled in, a certificate III or higher-level qualification, not including qualifications completed at school and foundation skills training?* Yes No If yes, tick any applicable boxes below* Bachelor’s 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 Other education (not specified/overseas qualifications) Please specify:* Language, literacy and numeracy, prior education, disability, employment status, cultural backgroundIn which country were you born?* Australia Other Please specify:* Do you speak another language other than English at home?* No, English only Other Please specify:* Do you identify as Aboriginal/Torres Strait Islander descent?* No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Do you consider yourself to have a disability, impairment or long-term condition? No Yes Please indicate the area/s of disability, impairment or long-term condition from the following list: Hearing/deaf Physical Intellectual Learning Mental illness Acquired brain impairment Visual Medical condition Other Please specify:* Are you still enrolled in secondary or senior secondary education?* No Yes Which best describes your current employment status?* Full-time Part-time Casual Unemployed - seeking full-time work Unemployed - seeking part-time work Unemployed - not seeking employment Employed - unpaid worker in a family business Employer Self-employed Select the one which best describes the main reason you are undertaking this course?* To get a job To develop my existing business To start my own business To try 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 To get skills for community/voluntary work Other Please specify:* How well do you read?* Very well Well Require assistance How well do you write?* Very well Well Require assistance Do you have a reasonable level of physical fitness? (i.e. ability to bend and complete manual handling tasks)* Yes No Do you have access to a computer / laptop with high- speed internet?* Yes No Are you employed in the community services industry as a support worker, or in a similar occupation?* Yes No Employer name* Street address* Contact person* Phone*Email* Do you have any experience or qualification(s) relevant to the course you are applying for?*Would you like to apply for Recognition of Prior Learning (RPL) or a Credit Transfer?*Please refer to your Learner Handbook for more information about RPL and Credit Transfers. Alternatively, you can contact a breakthru staff member if you need more information.Do you require any assistance in order to complete your course?*Privacy Notice To learn how we use your personal information for enrolment, please visit our privacy policy page. Student Declaration I declare that: All information I have provided to breakthru College, in connection with this application is true, accurate and not misleading in any way; I confirm that I have been provided with the details of the fee chargeable; I confirm that I have read and understood the information specified in the breakthru Learner Handbook. I accept the responsibilities of my actions and agree to abide by the conditions outlined in the Breakthru Learner Handbook. Student Declaration and Consent By signing this enrolment form, you agree with all the information outlined in the Student Declaration and the breakthru Learner Handbook.Student signature*Date* MM slash DD slash YYYY Parent/guardian signature(Parent/guardian signature is required for all students under the age of 18)Date MM slash DD slash YYYY Do you have a Unique Student Identifier (USI)?* Yes No Unique Student Identifier (USI) From 1 January 2015, Breakthru can be prevented from issuing you with a nationally recognised VET qualification or statement of attainment when you complete your course if you do not have a Unique Student Identifier (USI). In addition, we are required to include your USI in the data we submit to NCVER. If you have not yet obtained a USI you can apply directly at https://www.usi.gov.au/students/create-your-usi on a computer or mobile device. Enter your Unique Student Identifier (USI) (if you already have one) You may already have a USI if you have done any nationally recognised training, which could include training at work, completing a first aid course or RSA (Responsible Service of Alcohol) course, getting a white card, or studying at TAFE or training organisation. It is important that you try to find out whether you already have a USI before attempting to create a new one. You should not have more than one USI. To check if you have already have a USI, use the “forgotten USI” link on the USI website at https://www.usi.gov.au/faqs/i-have-forgotten-my-usi/ The USI is a reference number made up of ten numbers and letters.My Unique Student Identifier (USI) is:* USI application through your RTO (if you do not already have one) If you would like Breakthru to apply for a USI on your behalf you must authorise us to do so and declare that you have read the privacy information at < https://www.usi.gov.au/about-us/privacy > You must also provide some additional information as noted so that we can apply for a USI on your behalf.Consent I authorise breakthru to apply pursuant to sub-section 9(2) of the Student Identifiers Act (Cth) 2014, to create a USI on my behalf. I have read and I consent to the collection, use and disclosure of my personal information (which may include sensitive information) pursuant to the information detailed at https://www.usi.gov.au/documents/privacy-notice-when-rto-applies-their-behalfStudent signature*Date* MM slash DD slash YYYY Please upload forms of identity document below to allow for creation of your USI:*Please upload 100 points of identification, including at least 1 primary document (i.e. Driver's License) and 1 secondary document (i.e. Medicare Card) Drop files here or Select files Max. file size: 100 MB. Please upload forms of identity document below:*Please upload 100 points of identification, including at least 1 primary document (i.e. Driver's License) and 1 secondary document (i.e. Medicare Card) Drop files here or Select files Max. file size: 100 MB. In accordance with section 11 of the Student Identifiers Act (Cth) 2014, breakthru will securely destroy personal information which we collect from individuals solely for the purpose of applying for a USI on their behalf as soon as practicable after we have made the application or the information is no longer needed for that purpose. The following is provided to you on behalf of the Student Identifier Registrar (Registrar). You are advised and agree that you understand and consent that the personal information you provide in connection with your application for a Unique Student Identifier (USI): Is collected by the Registrar as authorised by the Student Identifiers Act (Cth) 2014. Is collected by the Registrar for the purposes of: Applying for, verifying and giving a USI; Resolving problems with a USI; and Creating authenticated vocational education and training (VET) transcripts; May be disclosed to: Commonwealth and State/Territory government departments and agencies and statutory bodies performing functions relating to VET for : The purposes of administering and auditing VET, VET providers and VET programs; Education related policy and research purposes; and To assist in determining eligibility for training subsides; VET Regulators to enable them to perform their VET regulatory functions; VET Admission Bodies for the purposes of administrating VET and VET programs; Current and former Registered Training Organisations to enable them to deliver VET courses to the individual, meet their reporting obligations under the VET standards and government contracts and assist in determining eligibility for training subsides; Schools for the purposes for delivering VET courses to the individual and reporting on these courses; The National Centre for Vocational Educational Research for the purpose of creating authenticated VET transcripts, resolving problems with USIs and for collection, preparation and auditing of national VET statistics; Researchers for education and training related research purposes; Any other person or agency that may be authorised or required by law to access the information; Any contractually engaged by the Student Identifiers registrar to assist in the performance of his or her functions in the administration of the USI system; and Will not otherwise be disclosed without your consent unless authorised or required by or under law. The consequences for not providing the Registrar with some or all of your personal information are that the Registrar will not be able to issue you with a USI. You can find further information on how the registrar collects, uses and discloses the person information about you in the Registrar’s Privacy Policy or by contacting the Registrar on usi@education.gov.au or telephone 1300 857 536, international inquiries +61 2 6240 8740. The Registrar’s Privacy Policy contains information about how you may access and seek correction of the person information held about you and how you make a complaint about a breach of privacy by the Registrar in connection with USI and how such complaints will be dealt with. You may also make a complaint to the Information Commissioner about an interference with privacy pursuant to the Privacy Act 1988, including in relation to the misuse or interference of or unauthorized collection, use, access, modification or discloser of USIs.PhoneThis field is for validation purposes and should be left unchanged.
