First Aid Enrolment Form

Select First Aid date*

Saturday 2 November 2019
Monday 16 December 2019
Thursday 23 January 2020
Sunday 16 February 2020
To be confirmed

Name*

First Last

Date of Birth*

Phone*

Email*

Preferred method of contact?*

Phone (during business hours)
Phone (outside business hours)
SMS
Email

Do you have any disabilities that may impact your ability to study?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

If yes, please provide details below:

Do you have any medical conditions or injuries that may impact you from participating in exercise?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

If yes, please provide details below:

Are you pregnant?*

Yes
No

If yes - please download medical clearance from here download medical clearance. Please fully complete THIS FORM and have it signed by a Doctor and emailed to info@h-p-c.com.au PRIOR to course commencement.

Gender*

Male
Female

Emergency / Next of Kin Contact

First Person

Name*

First Last

Phone*

Relationship to you*

Second Contact Person

Name*

First Last

Phone*

Relationship to you*

Your Residential Address*

Street Address Suburb State Postcode Country

ID File Uploader (10MB Limit) Page 1 (ID is required for student record identity purposes)*

ID File Uploader (10MB Limit) Page 2 (optional)

Are you of Aboriginal or Torres Strait Islander origin?*

No
Yes - Aboriginal
Yes - Torres Strait Islander

Are you still attending secondary school?*

Yes
No

If yes, L.U.I. number

Is English your first language?*

Yes
No

Other language (please specify)

How well do you speak English?*

Very Well
Well
Not Well
Not At All

In which country were you born?*

Australia
Other

Other country (please specify)

What is your highest completed school level?*

Which year did you complete that school level?*

Of the following categories, which best describes your current employment status?*

Full-time Employee
Part-time employee
Employed – unpaid worker in a family business
Self-employed – not employing others
Unemployed – seeking part-time work
Unemployed – seeking full-time work
Not employed – not seeking employment

Of the following categories, which best describes your main reason for undertaking this course?*

Have you successfully completed any of the following qualifications? If YES, then tick ANY applicable boxes.

Bachelor Degree or Higher Degree
Advanced Diploma or Associate Degree Certificate II
Certificate IV (or Advanced Certificate/Technician)
Certificate III (or Trade Certificate)
Diploma (Or Associate Diploma Certificate)

How did you hear about us?*

Are you an Australian resident?*

Yes
No

Do you have a current visa?

Yes
No

I am happy for Human Performance Centre to source my USI (Unique Student Identifier) on the Australian Government website should the need arise.*

Yes
No

Notes/Comments

I have read and understood the contents of the HPC student handbook*

Yes

I have read and understood all Terms and Conditions associated with enrolment*

Yes

Payment Method*

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