Enrolment Form

Personal Details

Name*

Given Name Surname

Date of Birth*

Gender*

Male

Female

Other

Residential address*

Street Address Address Line 2 Suburb State Postcode

Phone number*

Mobile number

Phone number*

Mobile number*

Email*

Next of kin*

Next of kin - Phone number*

Employer*

Occupation*

Unique Student Identifier Number*

If you don't have a USI number- click here to create one: Create USI

Reason for undertaking

Of the following categories, which BEST describes your main reason for undertaking this course/traineeship/apprenticeship?

To get a job

To develop my existing business

To try for a different career

To get a job or promotion

It is a requirement of my job

I want extra skills for my job

To get into another course of study

For personal interest or self development

Other reasons

Enrolment Confirmation

Consent

I grant Prosafe permission for use of photos of myself to be used and for CSQ to contact me.

I grant permission to Prosafe to use images of myself. Such use includes the use of photographs, images, and/or videos taken for use in training
materials that include, but may not be limited to, printed materials such as textbooks, brochures, newsletters, videos, and digital images used on the Prosafe website and social media pages, surveys, and/or contacting the Participant advising of products and services – current or future.

Consent*

I grant CSQ permission to contact me

I give written consent to enable CSQ to contact me for the purposes of any review, conducting surveys and/or contacting the Participant advising of products and services – current or future.

Signature

Name

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Enrolment Form

Personal Details

Origin/ Disabilities

Education

Reason for undertaking

Enrolment Confirmation

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