"*" indicates required fields 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 AssistanceProvide First AidTuggerah Part QualificationBankstown Part QualificationName* First Middle Last Town / City of birth* Gender* Male Female Other Date of birth* DD slash MM slash YYYY Mobile*Home phoneWork phoneEmail* Alternative email address How did you hear about this course?*GoogleFacebookEventReferralRadioOutdoor BillboardIndoor BillboardTelevisionOtherPlease specify* Emergency Contact Name* Relationship* Emergency Contact Mobile* 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 OptionalFlat / Unit Number OptionalStreet Address* e.g. 123 Smith StreetSuburb* State / Territory* Postcode*Is this address also your postal address?*YesNoWhat is your postal address (if different from above)?Address Suburb State / territory Postcode Do you have a disability, impairment or long-term condition?* No disability Yes, I have a disability, impairment or long-term condition I am a child or spouse of a person receiving the Disability Support Pension (DSP) If you chose “no disability” from the above, please indicate your welfare status:* Welfare recipient Dependent child or spouse of a welfare recipient Not a welfare recipient Please indicate the area(s) of disability, impairment or long-term condition:* Hearing/deaf Physical Intellectual Vision Learning Mental illness Acquired brain impairment Medical condition Other Centrelink or Veteran Affairs status* Not a Centrelink/Veteran Affairs Recipient A Centrelink/Veteran Affairs Recipient Dependent child/spouse of Centrelink/Veteran Affairs Recipient Please specify type of Centrelink/Veteran Affairs Recipient* Citizenship and residency status* Australian Citizen Australian Permanent Resident Humanitarian Visa New Zealand Citizen Do you identify as being of Aboriginal / Torres Strait Islander descent?* No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Are you living in NSW social housing OR is your household on the NSW Housing Register?* No Yes Have you undertaken any other Smart and Skilled qualification this calendar year?* No Yes Are you an Employment Service Provider (JSA) client?* No Yes If yes, please provide the following details:JSA Name: Your Client ID: Are you enrolled under a waiver?*(Asylum/Humanitarian/Protection/Safe Haven Visas) No Yes Are you still at school? (secondary or senior secondary education)* No Yes What is your highest completed school level?* Year 12 or equivalent Year 11 or equivalent Year 10 or equivalent Year 9 or equivalent Year 8 or below Never attended school Have you successfully completed any of the qualifications listed since turning 17 years old?*- Bachelor's degree or higher - Advanced diploma or associate degree - Diploma (or associate diploma) - Certificate IV (or advanced certificate/technician) - Certificate III (or trade certificate) No Yes 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 I Other education (not specified/overseas qualification/s) Please specify:* Are you registered or intending to be registered in an Apprenticeship or Traineeship for this qualification in NSW?* No Yes Do you have any barriers to learning* No Yes 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:* Which best describes your current employment status?*For casual, seasonal, contract and shift work, use the current number of hours worked per week to determine whether full time (35 hours per week or more) or part-time employed (less than 35 hours per week) 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 Unemployed - not seeking employment 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 as the role and work placement component of this qualification require you to physically assisting clients which involves bending and manual handling tasks?* Yes No Do you have access to a computer / laptop with high- speed internet?* Yes No 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 & Student Declaration To learn how we use your personal information for enrolment, please visit our privacy policy page.Student Declaration As part of the enrolment, you are required to meet certain criteria and disclose information to assist in the eligibility process. Please note that this training is subsidised by the NSW Government. The NSW Smart and Skilled details are as follows: Smart and Skilled website: https://smartandskilled.nsw.gov.au/ Contact details: 1300 772 104 I declare the following to be true and accurate statements:* I live and work in NSW (determined by postcode of the usual place of residence or place of work) OR An Aboriginal and Torres Strait Islander student who does not live or work in NSW but lives in specific defined interstate NSW border areas are also eligible for government-subsidised training; I am an Australian citizen OR a permanent Australian resident OR a New Zealand citizen OR a humanitarian visa holder OR a partner visa holder whose sponsor is a humanitarian visa holder; I am 15 years old or older; I am no longer in secondary education; I will communicate cancellation of the training agreement in writing to training@breakthru.org.au. I understand that my enrolment in the above qualification may be subsidised by the NSW and Commonwealth Governments under the NSW Smart and Skilled program. I understand that enrolling in the above qualification may affect future training options and eligibility for further Government subsidised training under the Smart and Skilled program; All information I have provided to breakthru College, in connection with this application for a NSW Smart and Skilled course subsidy is true, accurate, complete 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. I confirm that I have read, understood and agreed the information specified in the Enrolment Notice Consent Form. I have understood the course requirements including the entry requirements by accessing our website at breakthru College - Disability & Community Services Training. Student Declaration and Consent By signing this enrolment form, you agree with all the information outlined in the Student Declaration and the Student signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Parent/guardian signature(Parent/guardian signature is required for all students under age of 18) Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Media Release*I hereby grant breakthru the irrevocable and unrestricted right to use, reproduce and publish photographs and recordings taken of me, including my image and likeness as depicted therein, and any statement or testimonial made by me for editorial, trade, advertising or any other purpose in any manner and medium, and to alter the same without restriction. Yes No 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. 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* Reset signature Signature locked. Reset to sign again 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.CommentsThis field is for validation purposes and should be left unchanged.
