CONFIDENTIAL
DV-alert Face to Face Workshop - Enrolment Form
CHCDFV301A Recognise and Respond Appropriately to Domestic and Family
Violence
Please note that all fields with an asterix(*) must be completed or your
registration form will not be accepted
Location: WOOLGOOLGA – Woolgoolga Neighbourhood Centre, Cnr
Beach & Boundary Streets
Dates: 18-19 February 2014
Registration type:
Title: (Mrs. Ms. Mr.
etc)
Last Name:*
First Name:*
Sex:
Date of Birth:*
Female
Male
Postal Address:*
State:*
Phone:* (
)
Fax Number: (
Post Code:*
Mobile:
)
Email:*
Occupation:*
Dietary requirements:*
AVETMISS
Country of Birth:*
Indigenous Status:*
Aboriginal
Aboriginal AND Torres Strait Islander
Torres Strait Islander
Neither
Main language spoken at
home:
English proficiency:
Very well
Not very well
Well
Not at all
Highest Completed School
Level:
Did not go
Year 9 or equivalent
Completed Year 11
Year 8 or below
Completed Year 10
Completed Year 12
Year
Completed:
Year highest school level completed
At secondary school
Employment status:
© Lifeline
Yes
No
Full-time employee
Part-time employee
Self-employed- not employing others
Employer
Employed – unpaid worker in a family business
Unemployed – seeking full-time work
Unemployed – seeking part-time work
Not employed – not seeking employment
January 2014
To get a job
To develop my existing business
To start my own business
To try for a different career
To get a better job or promotion
It was a requirement of my job
Reason for study
I wanted extra skills for my job
To get into another course of study
For other reasons
For personal interest or self-development
Yes
Do you to have a disability, impairment, or long-term condition?
No
If "Yes" Check appropriate option(s):
Hearing/Deaf
Acquired Brain Impairment
Physical
Vision
Intellectual
Medical Condition
Learning
Other:
Mental Illness
Unspecified:
This information is collected and used solely as part of the application for training, in line with the
10 National Privacy Principles under the Privacy Act 1988. Lifeline Australia’s Privacy Policy can
be found at www.lifeline.org.au/lib/privacy
I certify that all the above details are correct and that I have read the terms and
conditions listed on page 3 and 4.
Signature of Applicant
Date
If you have any questions about enrolment or the training please contact:
DV-alert Program Administration Officers
Phone: 02 6215 9418
Email: dvalert@lifeline.org.au
Please email the completed form to the DV-alert Program Administration Officer via
dvalert@lifeline.org.au and you will receive an email confirmation with pre-reading
and details on venue and workshop.
© Lifeline
January 2014
Terms & Conditions
Enrolments
All enrolments are subject to course availability and acceptance of enrolment application.
Transferring Enrolments
In the event that the trainee is unable to commence the course originally chosen for enrolment, they
may request a transfer to another scheduled course date.
The request will be subject to availability and management discretion.
Enrolments may not be transferred to another trainee unless agreed by Lifeline National Office.
Refunds and Cancellations
Lifeline reserves the right to change the designated venue or speaker, or both, on any event
described in its course catalogue.
Lifeline further reserves the right at its absolute discretion and without liability to cancel, an advertised
course due to insufficient bookings or through circumstances beyond the reasonable control of the
company.
Course Material/Intellectual Property
COMMONWEALTH OF AUSTRALIA
Copyright Regulations 1969
WARNING
This material has been reproduced and communication to you by or on behalf of Lifeline pursuant to
Part VB of the Copyright Act 1968 (the Act).
The material in these communications may be subject to copyright under the Act. Any further
reproduction or communication of this material by you may be the subject of copyright protection
under the Act.
Lifeline Practice Model and National CS Training are copyrighted to Lifeline. It is essential that this
copyright is respected to protect Lifeline's intellectual property.
Lifeline has a copyright licence from the Copyright Agency Ltd (CAL) which provides a legal means for
Lifeline to access external copyright material and provide fair payment to creators and publishers for
use and copying of their works.
To abide by our CAL licence Lifeline must track use of all copyrighted materials.
Certificates
Certificates are awarded at the discretion of the trainer and only to trainees who are deemed as
successfully having completed the training. Certificates are NOT issued purely for attendance unless
otherwise agreed prior to the course being carried out and in which case the certificates will be
worded appropriately.
Enrolment Validity
Your enrolment is valid for the duration of the enrolled course.
Within this period you are required to complete all course work and assessment as detailed in the
course outline accessible on the home page of http://lifeline-tms.org.au/.
© Lifeline
January 2014
Privacy Policy
Lifeline's privacy policy is available for viewing here
Complaints
Complaints in writing should be addressed to:
Lifeline Australia
PO Box 173
Deakin West ACT 2600
or
via Lifeline complaints line 1800 424101
For further information on complaints, grievances and appeals processes, please contact
Lifeline National Office 02 6215 9400
© Lifeline
January 2014