STUDENT ENROLMENT
FORM
239 White Road Wonthaggi Vic 3995
Before filling out this form, please ensure you have read and understood all information given to you regarding your training.
Please ensure you read and sign the declaration at the end of the form. If you have any questions, please contact the centre on
56723115 or at info@basscoastadulted.org.au
PLEASE SIGN THE BACK OF THIS FORM WHEN COMPLETED
Name of course
Course/Training Name if known:
How did you hear about this training?
❑ Brochure
❑ Local paper ❑ Friend/relative
❑ Website
❑Social media
❑ Agency ❑ Other _____________
Personal Information
Family Name _________________________________________________ Former Surname______________________
Given Names ________________________________________________________ Title_________________________
Please give name accurately and legibly as they will be used on any certificates or results issued to you
Date of Birth (dd/mm/yyyy)
____/____/_______ **
Male ❑ Female ❑
Gender :
**City/town of Birth: ________________________________________________________________________________
Residential Address
Street___________________________________________________________________________________________
Town ______________________________________________State __________________ Post code _____________
Postal Address
❑ As above
OR
PO Box or RMB Number _________________________________________________________
Town ______________________________________________ State ___________________ Postcode ____________
Contact details
Home phone ______________________________________ Work phone _____________________________________
Mobile ________________________________________ Email ______________________________________________
Preferred contact Method:
 Email
 Mobile
 Mail
Unique Student Identifier (USI) Number (ask admin if not sure of this – they will help you apply for this)
USI: ____________________________________________________________________________________________
Your Victorian Student Number
Do you have a Victorian Student Number (VSN)?
Yes ______________________________________ Yes but unknown ❑
No never issued ❑
Don’t know ❑
Emergency Contact
Person ________________________________________ Relationship to you___________________________
Phone_________________________________________ Mobile _____________________________________
Citizenship & Language
Are you and Australian Citizen?
Yes ❑ No ❑ If NO which country were you born? ____________________________
Yes ❑ No ❑ If YES, which language? ___________________________
Do you speak a language other than English?
How well do you speak English?
Very well ❑
Well ❑
(if from non-English speaking background)
Not well ❑
Not at all ❑
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If you are NOT a permanent resident or citizen of Australia
PLEASE BRING YOUR PASSPORT/LATEST VISA WHEN ENROLLING
Originating country (on passport) _____________________________Date arrived in Australia ___________________
Passport No _____________________________________ Visa No__________________________________________
Visa subclass number/type __________________________________________ Visa expiry date___________________
Cultural Background
Are you of Aboriginal or Torres Strait Islander origin?
No ❑
Aboriginal ❑ Torres Strait Islander ❑ Both ❑
Secondary schooling
Are you still in secondary school?
Yes ❑ No ❑
What is the highest level you SUCCESSFULLY COMPLETED in SECONDARY school in Australia?
Year 12 ❑
Year 11 ❑
Year 10 ❑
Year 9 ❑
Year 8 or below ❑
Did not go to school ❑
What year did you complete this level? ___________________ Where? ________________________________________
Current employment status
Which best describes your current employment status?
▢ Full time employee
▢ Unemployed – unpaid worker in a family business
▢ Part-time employee
▢ Unemployed – seeking full-time work
▢ Self-employed - not employing others
▢ Unemployed – seeking part-time work
▢ Employer – employing more than 1 staff
▢ Not employed – not seeking employment
Field of Employment
What best describes your industry?
▢ Agriculture, Forestry & Fishing
▢ Mining ▢ Manufacturing ▢ Electricity, Gas, Water & Waste Services
▢ Construction
▢ Wholesale Trade
▢ Retail Trade
▢ Accommodation & Food Services
▢ Transport, Postal & Warehousing ▢ Information, Media & Telecommunications
▢ Financial & Insurance Services
▢ Rental, Hiring & Real Estate
▢ Professional, Scientific & Technical
▢ Admin & Support Services
▢ Public Admin & Safety
▢ Health Care & Social Assistance
▢ Education & Training
▢ Arts & Recreation Services
▢ Other
What best describes your position?
▢ Manager
▢ Professional ▢ Technician or Trade worker
▢ Community & Personal service
▢ Sales
▢ Clerical & Admin ▢ Machinery Operator or Driver ▢ Labourer ▢ Other
Do you have a CENTRELINK concession?
Do you have a Centrelink concession card?
▢ No
▢ Yes (please show at enrolment)
If yes, complete the following
Type _____________________ CRN number ___________________________________ Expiry date ________________
(Proof sighted  By whom: …………………………………………………………………………………………………………………………………)
Do you have a disability?
Do you consider yourself to have a disability for which you may require assistance? No ❑ Yes ❑ (please specify)
▢ Hearing
▢ Vision
▢ Intellectual ▢ Learning
▢ Mental illness ▢ Acquired Brain Injury (ABI)
▢ Physical
▢ Medical Condition ▢ Other __________________________________________________________
Do you have a medical condition we may need to know about?
Do you have any pre-existing ailments (requiring possible treatment) that we need to know about: Yes
No
If yes, please give following details
Medication to be kept at Centre Yes No
Type _______________________________________________
Have you briefed staff on required emergency actions to be taken? Yes No
Ambulance subscriber Yes No
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Reason for study
▢ To get a job
▢ To get a better job or promotion
▢ To develop my existing business
▢ For personal interest/self-development
▢ It was a requirement of my job
▢To get into another course of study
▢To start my own business
▢ I wanted extra skills for my job ▢To try for a different career ▢Other reasons
Do you wish to apply for Credit Transfer (CT) or Recognition of Prior Learning (RPL)?
Are you applying for CT or RPL against any of this training (if relevant)?
▢ Yes
▢ No
▢ Not sure (please ask your enrolling officer about this if unsure)
Permissions
Do you give permission for
Your work to be placed on view in the centre (if relevant)
▢ Yes
▢ No
Your image to appear in our publicity – brochure, local print media, centre handbooks
Education history – GOVERNMENT SUBSIDISED TRAINING only – Section B - VTG
Q1. The highest qualification you currently hold is:
▢ Yes
▢ No
_______________________________________________________________________________________________
(Include full title of qualification eg. Certificate III in Aged Care)
Q2. Not including the course/s you are seeking to enrol in now, how many other government subsidised courses have you
enrolled to undertake this year? (Include training you have enrolled in to undertake at this and other training providers but not yet started)
0
1
2
3
4+
(circle number)
Q3. Not including the course/s you are seeking to enrol in now, how many other government subsidised courses are you
undertaking training in at the moment?
0
1
2
3
4+
(circle number)
Q4. In your lifetime, how many government subsidised courses have you started (commenced) that are at the same level
as the one you are applying for now? (do not answer this question if you are seeking to enrol in a course that is on the Foundation
Skills List - ask admin for clarification of this)
0
1
2
3
4+
(circle number)
I (student)_____________________________________________________________________, in seeking to enrol in
___________________________________________________________________________________________________
Declare the following to be true and accurate statements:
a. I AM / AM NOT enrolled in a school, including government, non-government, independent, Catholic or home
school. (circle appropriate response)
b. I AM / AM NOT enrolled in the Commonwealth Government’s Skills for Education and Employment (SEE) program.
(circle appropriate response)
c. I understand that my enrolment in the above qualification/s is being subsidised by the Victorian and Commonwealth
Governments under the Victorian Training Guarantee*. I understand that enrolling in the above qualification/s may
affect my future training options and eligibility for further government subsidised training under the Victorian
Training Guarantee.
Signed (student): __________________________________________________________ Date: ____________________
* Eligibility for Government subsidised training from June 2014. An individual is only eligible to:
a) Commence a maximum of two government subsidised courses in a calendar year, at any time within that year;
b) Undertake a maximum of two government subsidised courses at any one time;
c) Commence a maximum of two government subsidised courses at the same level within and Australian Qualification Framework (AQF) in
their lifetime; and
d) Commence a maximum of two government subsidised accredited courses with the title ‘Course in …’ in their lifetime.
NB: Qualifications listed on the Foundation Skills List (literacy & numeracy programs – see admin re meaning) will NOT count towards the course
maximums
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Course fees
Name of course ____________________________________________________________________________________
Date of enrolment ____________________________________________________________________
Student tuition contribution
$ ________________________
Other fee/s
$ ________________________ (Description of fee ___________________________ )
Total Fee Payable
$
•
Is an agency paying for your course
▢ No
▢ Yes
Declaration
I understand that Bass Coast Adult Education Centre is required to provide the Victorian Government (HESG) with student and training
activity data which may include information I provide in this enrolment form. Information is required to be provided in accordance with the
Victorian VET student statistical collection guidelines (which are available at www.skills.vic. gov.au/corporate/ statistics/submit.data).
HESG may use the information provided to it for planning, administration, policy development, program evaluation, resource allocation,
reporting and/or research activities. For these and other lawful purposes, HESG may also disclose information to its consultants,
advisers, other government agencies, professional bodies and or other organisations.
The Education and Training Reform Act 2006 requires Bass Coast Adult Education Centre to collect and disclose my personal
information for a number of purposes including the allocation to me of a Victorian Student Number and updating my personal information
on the Victorian Student Register.
I have been given information upon enrolment, have read and understood it. I agree to be bound by the centres’ policies and procedures
and code of conduct whilst enrolled as a student here. I agree to the release of my personal/medical information for educational reasons
or to meet legal obligations or in the case of an emergency, as authorised in accordance with privacy policies and legislation.
I have been made aware of, read, understood and agree with all fees and charges applying to this course prior to signing this form. This
information includes course cancellations and refunds. I understand that should I need to travel in any staff member’s vehicle that staff
members and/or this centre will take every care but no responsibility during travel times.
I agree that I am entitled to a Statement of Attainment at no extra cost, for each unit completed and fully paid for. However reprints of
certificates and Statements of Attainment will incur a fee.
I acknowledge and agree with the terms described above and those set out in all Student information given to me. I agree with the
Individual Training Plan that has been created by the Centre staff for me. I understand that I can request information on this and request
changes when and where I require it, and agree to make changes when required.
I acknowledge and agree to the terms, conditions and privacy statement above. I declare that the information provided on this enrolment
form is, to the best of my knowledge true, correct and complete at the time of my enrolment. I acknowledge that any false information
and/or failing to disclose any relevant information to my application for enrolment may result in the withdrawal of any enrolment,
particularly as it relates to my eligibility to obtain an offer of government subsidised training and/or cancellation of enrolment at the
discretion of the Bass Coast Adult Education centre.
Student Signature
Date (dd/mm/yyyy) _____/ _____/ ________
OFFICE USE ONLY
Identity Document Presented: ……………………………………………………………………………………………………(P’copy Attached)
Evidence of citizenship/residency/concession and age: Document/s sighted: ……………………………………………………….…………
Number of courses student is currently eligible for:  1
2
RTO declaration
Based on discussion with the student, the above evidence I have sighted and the information provided to me by the student in section B
of this form I believe that the above individual satisfies the Victorian Training Guarantee eligibility criteria as set out in the VET funding
contract and is eligible for funding under the Victorian Training Guarantee for the following qualification/s:
_____________________________________________________________________________________________________________
(full title of qualification/s in which student is seeing to enrol)
Authorise RTO delegate:
Name: ____________________________________ Position: __________________________________
Signed: _____ ___________________________________________________Date: _____________/_______/___________________
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USI APPLICATION Student Permission Form
(to be attached to the student Enrolment Form)
Student Full Name:……………………………………………………………………………………………… Date: …………………………
From January 2015, it is compulsory for all new students enrolling in Government Funded training to apply for
and obtain a Unique Student Identifier (USI). This process is an Australian Government initiative, and required
you to answer a number of questions, and to provide an identity document that will be processed by
Government Document Verification Service (DVS) .
Whilst the Government strongly advises that you apply for this yourself, we can apply for this for you. If you
want is to do this for you, we need you to answer a few questions, provide an identify document (list attached)
and give us permission to apply on your behalf.
The USI will allow you to have a record of all qualifications you have gained over your lifetime, even if you lose
your certificate.
If you do wish us to go ahead with the application, please supply the following information:
Date of Birth: …………………………………………Town or City or Birth: …………………………………………………………………
Country of Birth: …………………………………………..…………
Preferred Contact Method:
 Email
Gender:
 Mobile
 Male  Female…………….…….
 Mail
Home Phone Number: ……………………………… Mobile Phone Number: ………………………………………………………
 Identity Document supplied – see below ( or details entered below)
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Eligible Identity Documents –
PLEASE ENTER DETAILS HERE OR ATTACH PHOTOCOPY SHOWING ALL DETAILS
Document
Details required
Birth
Certificate :
ACT, NT, SA,
Birth
Certificate:
NSW, VIC, WA
Birth
Certificate:
QLD
Birth
Certificate:
TAS
Certificate of
registration by
a Descent
Citizenship
certificate
(Australian)
IMMI card
Registration Number:
Date Printed:
Registration Number:
Registration Year:
Registration Number:
Registration Date:
Registration Year:
Registration Number:
Driver’s
license
(Australian)
Medicare card
License Number:
State:
Colour:
 Green
 Blue
 Yellow
Expiry Date:
Name on Card:
Medicare Card Number:
Does the name appear on ONE
line?
Yes No
Individual reference
number:
Certificate Number:
Registration Date
Acquisition Date:
Acquisition Date:
Stock Number:
IMMI card number:
Passport
(Australian)
Document Number:
Visa (nonAustralian)
Passport Number:
Country of issue
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Please read the following Privacy Notice
If you do not already have a Unique Student Identifier (USI) and you want Bass Coast Adult Education Centre
(BCAEC) to apply for a USI to the Student Identifiers Registrar (Registrar) on your behalf, BCAEC will provide to the
Registrar the following items of personal information about you:
your name, including first or given name(s), middle name(s) and surname or family name as they appear in an
identification document;
your date of birth, as it appears, if shown, in the chosen document of identity;
your city or town of birth;
your country of birth;
your gender; and
your contact details.
When we apply for a USI on your behalf the Registrar will verify your identity. The Registrar will do so through the
Document Verification Service (DVS) managed by the Attorney-General's Department which is built into the USI
online application process if you have documents such as a Medicare card, birth certificate, driver licence, Australian
passport, citizenship document, certificate of registration by descent, ImmiCard or Australian entry visa.
If you do not have a document suitable for the DVS and we are authorised to do so by the Registrar we may be able
to verify your identity by other means. If you do not have any of the identity documents mentioned above, and we
are not authorised by the Registrar to verify your identity by other means, we cannot apply for a USI on your behalf
and you should contact the Student Identifiers Registrar.
In accordance with section 11 of the Student Identifiers Act 2014 Cth (SI Act), we will securely destroy personal
information which we collect from you solely for the purpose of applying for a USI on your behalf as soon as
practicable after the USI application has been made or the information is no longer needed for that purpose, unless
we are required by or under any law to retain it.
The personal information about you that we provide to the Registrar, including your identity information, is
protected by the Privacy Act 1988 Cth (Privacy Act). The collection, use and disclosure of your USI are protected by
the SI Act.
If you ask BCAEC to make an application for a student identifier on your behalf, BCAEC will have to declare that
BCAEC has complied with certain terms and conditions to be able to access the online student identifier portal and
submit this application, including a declaration that BCAEC has given you the following privacy notice:
You are advised and agree that you understand and consent that the personal information you provide to us in
connection with your application for a USI:
is collected by the Registrar for the purposes of:
o applying for, verifying and giving a USI;
o resolving problems with a USI; and
o creating authenticated vocational education and training (VET) transcripts;
may be disclosed to:
o Commonwealth and State/Territory government departments and agencies and statutory bodies performing
functions relating to VET for:
the purposes of administering and auditing Vocational Education and Training (VET), VET providers and VET
programs;
education related policy and research purposes; and
to assist in determining eligibility for training subsidies;
o VET Regulators to enable them to perform their VET regulatory functions;
o VET Admission Bodies for the purposes of administering VET and VET programs;
o 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 subsidies;
o schools for the purposes of delivering VET courses to the individual and reporting on these courses;
o the National Centre for Vocational Education Research for the purpose of creating authenticated VET transcripts,
resolving problems with USIs and for the collection, preparation and auditing of national VET statistics;
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o researchers for education and training related research purposes;
o any other person or agency that may be authorised or required by law to access the information;
o any entity 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.
Privacy policies and complaints
You can find further information on how the Registrar collects, uses and discloses the personal information about
you in the Registrar’s Privacy Policy or by contacting the Registrar on (email/telephone). The Registrar’s Privacy
Policy contains information about how you may access and seek correction of the personal information held about
you and how you may make a complaint about a breach of privacy by the Registrar in connection with the 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, which includes the following:
misuse or interference of or unauthorised collection, use, access, modification or disclosure of USIs; and
a failure by Us to destroy personal information collected by you only for the purpose of applying for a USI on your
behalf.
For information about how BCAEC collects, uses and discloses your personal information generally, including how you
can make a complaint about a breach of privacy, please refer to [insert name of organisation]’s privacy policy which can
be found at www.basscoastadulted.org.au
(Signature of acceptance by student)
…………………………………………………………………………………………………Date …………..………...
Name of student ……………………………………………………………………………………….……………..
Notes for RTO’s:
1. You may be an Australian Privacy Principle (APP) entity bound by the Privacy Act or an entity bound by State or Territory Privacy legislation. Please
consider whether your organisation is bound by any privacy legislation and if so, what your organisations obligations under such legislation would be.
2. Please note, in addition to the above, if your organisation contravenes sections 11, 16 or 17 of the SI Act, then pursuant to sections 23 of the SI
Act, your organisation will be considered to be an APP entity bound by the Privacy Act and the contravention may be subject to investigation by the
Information Commissioner.
3. Where your organisation is bound by Commonwealth or State or Territory Privacy legislation, your organisation may need to provide students,
either in connection with applying for the USI on their behalf or more generally as part of the enrolment information, advice about how the student’s
information is stored and protected, such as for example secure server at the RTO, third-party server in the cloud, or if hard-copy, in a locked
file/cupboard.
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