Enrolment Form

Personal Details

Name*

Given Name Surname

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Other

Residential address*

Street Address Address Line 2 Suburb State Postcode Country

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

Origin/ Disabilities

Country of birth

Australia

Other

Main language spoken at home*

English

Other

How well do you speak English?

Very well

Well

Not well

Not at all

Are you Aborginal or Torres Strait Islander?

Yes, Aboriginal

Yes, Torres Strait Is

Do you suffer from any disabilities?

Yes

Please indicate the areas of disability, impairment or long-term condition*

Hearing/ Deaf

Mental Illness

Physical

Intellectual

Vision

Medical Condition

Language

Literacy

Numeracy

Learning

Education

What is your highest completed school level?

Never attended school

Year 8

Year 9

Year 10

Year 11

Year 12

What year did you complete school?*

What is the highest qualification you have completed?*

Bachelor Degree

Advanced Diploma

Certificate IV

Certificate III

Certificate II

Certificate I

Other

What describes your current employment status?*

Full time

Part time

Self-employed

Employer

Unemployed

Not employed

Apprentice

Trainee

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

This field is for validation purposes and should be left unchanged.

Step 1

Confirm your Selection

Step 2

Complete your Payment

Step 3

Complete your Enrolment

Personal Details

Origin/ Disabilities

Education

Reason for undertaking

Enrolment Confirmation

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