Port Macquarie Community College - Enrolment Form for training courses

Name(required)

Address

Email Address (required)

Hm Phone (required)

Work Phone

Date of Birth

Were you born in Australia? YES NO

The following Information is collected nationally to assist government with educational planning.
These details will not be used for any purpose other than educational research.

Are you of Aboriginal/Torres Strait Islander Origin? YES NO

If Yes to the above, are you Aboriginal Torres Strait Islander Aboriginal &Torres Strait Islander

What language do you normally speak at home?
( If sign language please indicate which one )

If a language other than English, how well do you speak English?
Very well Well Not well Not at all

Which of the following would best describe your current employment?

Full Time Employee

Seeking Full Time Paid Work

Part time Employee

Seeking Part Time Paid Work

Employer

Not Seeking Paid Work

Employed - unpaid working in family business

Full Time Student Part Time Student

Self Employed - not employing others

Volunteer Worker Retired

Do you consider yourself to have a permanent or significant disability?

YES NO
If yes, please indicate the nature of your disability

Hearing/Deaf Physical Intellectual Learning Mental Illness
Acquired Brain Impairment Vision Medical Condition Other

Where did you hear about this course? Newspaper Radio TV Poster
Brochure delivered at home Friend Other

Education

What is your highest completed school level?
Year 12 Year 11 Year 10 Year 9 or lower In which year did you complete?

Have you successfully completed any of the following qualifications?

Bachelor Degree or Higher Degree

Trade Certificate

Advanced or Associate Diploma

Certificate II

Diploma

Certificate I

Advanced/Technician Cert (Cert IV)

Cert other than the above

Study Reason - from the following which BEST describes your main reason for doing the course?

For personal interest or self-development

To get a job

I want extra skills for my job

To get in to another course of study

It is a requirement of my job

To start my own business

To develop my existing business

To try for a different career

To get a better job or promotion

Other reasons

Course Details

Course Number	Course Name	Cost

PMCC Yearly Membership (Optional) $11.00 incl member card YES NO (GST incl)

I accept full responsibility for any injury to myself, or for loss or damage to my personal property as a result of my participating in the above class/classes, run by the Port Macquarie Community College. I warrant that I am physically and mentally fit enough to undertake the activity. I understand PMCC and tutors will take all reasonable care and I am aware of the risks so far as they are reasonably foreseeable. I have read and understand the enrolment conditions and refund policy of PMCC. Information that may be given in a course does not constitute 'advice'. PMCC accepts no responsibility and students should seek independent advice from a professional before acting on any information given.

Date of Submission

I have read and agree to the above statement. Please type the word YES in this box before you submit your form:

Click on the submit button below and a member of staff will contact you for payment details. PMCC accepts credit card and eftpos payments together with cheque and cash. Your e-mail enrolment will reserve a place in the class for 3 working days.

Payment Options

For Online Credit Card payments, complete the section below or leave this blank and one of our staff will contact you using the details you provided above.

Name on Card
Card type	Visa Mastercard Bankcard
Card Number
Expiry Date
Amount