WOMEN'S RETURN TO WORK CAREER INFORMATION
SESSIONS
PARTICIPANT REGISTRATION
A PERSONAL DETAILS
A1. What is your name?
Title
Given Name
Surname
A2. Where do you live?
Residential
Suburb
A3. How may we contact you?
State
Postcode
Daytime Phone
email
A4. Please indicate your preference for contact
Contact Method
A5. What sessions would you like to attend?
Please tick the session box, if all sessions
please tick all.
B MORE ABOUT YOU
Daytime phone
Email
Session 1
Session 2
Session 3
Session 4
Mail
All sessions
It is optional for you to provide the following information. CSD will use it for program administration,
research, evaluation and monitoring purposes.
B1. Are you on a low income?
No
Yes
B2. How long has it been since you last had paid work?
3 months
6 months
9 months
12 months or more
never worked
never worked in Australia (this
question is specifically for new immigrants
B3. What level of education do you have? This question is aimed to assist us in having the
sessions tailored to your needs
Primary education K-Year 6
Secondary education Year 7- 10
Year 11-12
Tertiary Certificate or Trade Certificate
Degree
Post graduate studies
B4. What do you hope to get out of these sessions? You may tick more than one box
Employment
Self esteem
Skills to enter the workplace
Skills for the workplace
Networking with other women in the
same situation
1|P age
B5. What kind of work are you interested in?
Administrative
Manual work
Business development
Human Services-childcare, community
work, aged or disability care
Executive roles
Sales
Other, please state
specifics...........................................................
.........................................................................
B6. Have you previously received assistance from the Return to Work grants program?
No
Yes. If yes, when?..................................
B7. Have you been out of the paid workforce due to caring responsibilities?
No
Yes
If so, who were you caring for? You may tick more than one box
Child/children
Spouse
Other family member
Their relationship to you:..............................................
Someone else’s child
Community members
.... Other (please specify): ........................................
B8. Do you speak another language other than English at home?
No
Yes, do you feel that you require an interpreter?__________________________________________________
B9. Are you Aboriginal or Torres Strait Islander?
No
Yes
B10. Do you have a disability?
No
Yes, do you have any special requirements?
__________________________________________________
__________________________________________________
B11. What age group do you belong to? (please circle)
16 – 25
26 – 35
36 – 45
46 – 55
56 – 65 66-75
Other ...................................................................................
2|P age
B12. Will you require childcare to be paid for by the program during these
sessions?
Session 1
__/__/__
Childs name
___/___/___
DOB
Child Care
Provider
Session 2
Contact
information
__/__/__
Childs name
___/___/___
DOB
Child Care
Provider
Session 3
Contact
information
__/__/__
Childs name
___/___/___
DOB
Child Care
Provider
Session 4
Childs name
Contact
information
__/__/__
Session 3
___/___/___
DOB
Child Care
Provider
B9. How did you hear about Women’s Return to Work Career Information
Sessions? Please tick.
Mother’s Group
Press article
Friend/Colleague
Government Federal
Government
Territory
Search Engine
Contact
information
Community
Organisation
email
Mail
Radio
TV
Training Provider
Other, please specify –
...................................................
Please return your registration to:
Rebecca.adams@act.gov.au
Or post to Return to Work Coordinator
Community Participation Group
GPO Box 158
Canberra City ACT 2601
3|P age