Registration Form

MRFEC Registration Form 2008

NO REFUNDS
Please check your enrolment carefuly. Except as required by the Trade Practices Act, we regret that a refund will only be given if a class does not proceed.

This registration form can be completed on-screen then printed, or printed blank then completed by hand.

Date:

Course Code

Fee

Concession

Employment Category

Full time employee

Part time employee

Self employed

Employer

Employed
Unpaid family worker

Unemployed
- Seeking Part-time work

Unemployed
- Seeking full-time work

Not employed
- not seeking employment

I am paying the amount of $

Cash

Cheque

Credit Card

Are you eligible for aConcession ?

Family Allowance / Parenting Single	Mature Age / Newstart / Youth Allowance
Age / Carers Disabilty Support	Sickness Allowance
Other	Low Income
Concession Type:	Concession No:

Do you consider yourself to have a disability, impairment or long-term condition ?		Yes	No
Physical	Intellectual	Visual	Chronic Illness
Hearing	Mental Illness	Acquired Brain Impairment	Medical Condition

Name and Address Information
Surname	FirstName		Title
Address			Postcode
Phone (H)	Phone(B)		Sex M F
Date of Birth	Country of Birth
Ages of children requiring childcare (under5)
Do you speak a language other than English at home ? Yes No	How well do you speak English? Very Well Well Not Well Not at all
Are you of Aboriginal or Torres Strait Islander origin ?	No	Yes Aboriginal	Yes Torres St Is

What is your highest level of Secondary Schooling completed ? (Please select one)
Year 12	Year 11	Year 10	Year 9	Year 8 or below	Year Completed

Since leaving school have you completed a qualification ?
If yes, please select one of the following
Bachelor Degree or Higher Degree	Advanced Diploma or Associate Diploma
Diploma	Certificate IV or (Advanced Certificate)
Certificate III (or Trade)	Certificate II
Certificate I	Other Certificate

Of the following categories, which BEST describes your reasons for undertaking this course. (Select one)
To get a job	I want exta skills for my job
To develop my existing business	To get into another course of study
To start my own business	For personal interest
To try for a different career	For self development
To get a better job or promotion	Other Reasons
It was a requirement for my job

Credit Card Details
Bankcard/Visa/Mastercard
Expiry Date	/	CardHolder Name
Signature

This form can be printed using

the icon in the toolbar at the top of your screen, or
the Menu command File...Print

Please send completed forms to:

MRFEC, P.O. Box 68,
Gisborne 3437

Or Fax to 5428 3278