"*" indicates required fields 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 AidBankstown Part QualificationTuggerah Part QualificationWhat is your role? I am from breakthru Royal Rehab Which breakthru/Royal Rehab office do you work at? Which breakthru office do you work at? Which Royal Rehab office do you work at? Have you previously completed any formal qualifications relevant to our industry? Yes No Please list relevant formal qualifications Name* First Last Date of birth DD slash MM slash YYYY Gender identity* Male Female Non-binary/genderfluid Different identity, please specify Specify gender identity* Mobile*Email* Street Address* e.g. 123 Smith StreetSuburb* 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 Recipient of Disability Support Pension Yes No Assessed by Specialist Support Professional Yes No 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 Smart and Skilled Student Declaration*To be eligible for NSW Skilling for Recovery funding, learners must meet all criteria from 1 to 5: Lives or works in NSW (as determined by postcode of the usual place of residence or place of work) OR An Aboriginal or Torres Strait Islander student who does not live or work in NSW but lives in specific defined interstate NSW border areas is eligible for government subsidised training under Smart and Skilled Is 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; Is aged 15 years or older Is no longer in secondary education; Must meet ONE of the following eight (8) categories:1. A Veteran2. A Veteran’s Recognised Partner (including spouse, recognised de-facto or ex-spouse/recognised de facto)3. A person aged 16 to 24 at commencement of training, regardless of employment status, including Year 12 school leavers4. A person who is a recipient of a Commonwealth Government welfare benefit (and their dependents)5. An unemployed person6. An employed person seeking to undertake training in construction and/or related industries, as follows:- An existing worker (e.g. a person currently employed in one of the construction or related industries) - A person who is currently employed in another industry, looking to reskill to obtain employment in construction or a related industry7. A person who is currently employed in the area of disability and aged care8. An employed person who is expected to become unemployed Staff member signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.