5 Willaton Street

St Albans VIC 3021

Phone: 1800 233 266
Email: info@advanced.edu.au
Web: www.advanced.edu.au

Student Enrolment Form

(Domestic Students-Victoria)

2. STUDENT ENROLMENT FORM

COURSE CHC50113 Diploma of Early Childhood Education and Care CHC30113 CERTIFICATE III in Early Childhood Education and Care

TITLE Mr. Mrs Miss Ms

STUDENT FULL NAME

(LEGALNAME)Please write thenamethat you used whenyouapplied for yourUnique Student Identifier(USI)

FirstName: (LegalName) Surname:(Legal FamilyName)

DATE OFBIRTH: (dd/mm/yyyy)

SEX Male. Female indeterminate/intersex/unspecified

CONTACT DETAILS

Home Phone: MobilePhone:

WorkPhone: EmailAddress:

RESIDENTIAL ADDRESS
Please providethe physicaladdress(street number &name not post-officebox) If you are from arural area use the addressfrom your state’s orterritories ruralproperty.

Building/Property Name:

Flat/Unit Number: Street / Lot Number

StreetName:

Town/Suburb

State: Postcode:

EMERGENCY CONTACT

Name Emergency contactrelationship to you

Mobile/Home phone/Workphone

LANGUAGE &CULTURALDIVERSITY

In which country were youborn? Do you speak a language otherthanEnglish athome?

Australia No, EnglishOnly

Other Country pleasespecify:_______________________ Yes, other pleasespecify

How well do you speak English? Are you of Aboriginal or TorresStrait Islander or Origin? (For person
odbothAboriginal and Torres Strait IslanderOrigin, mark both ‘Yes’
Very Well Boxes).

Well No

Not Well Yes,Aboriginal

Not at All Yes

© AdvancED Education & Training/ RTO 41332/ Student Enrolment Form Version 2.1