Advanced Clinical Training Enrolment Form

Advanced Clinical Training Enrolment Form
You will require about 20 minutes to complete this form. Please complete each section carefully. The form should be completed and submitted in one session, if you have any problems with the enrolment please contact us directly.

Missing or incomplete fields will be highlighted in red.

At the point of submitting your enrolment you will be required to pay a $200 non-refundable enrolment fee.
Course being applied for:*

Advanced Clinical Training in Somatics & Movement Therapy
Section 1 - Personal Details
First Name*
Family Name*
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Copy Address

Check this box if your postal address is the same as your residential address
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone
Format: (00) 0000-0000.
Work Phone
Format: (00) 0000-0000.
Mobile Phone
Format: 0000-000-000.
E-mail*
Confirm E-mail*
Date of Birth*

DayMonthYear
Under 18
Gender*

MaleFemaleN/A
Emergency / Next of Kin Contact Details:
Emergency Name
Emergency Phone
As of January 1st, 2015 you are required to provide your USI.

If you do not have one, click here to obtain one through the Department of Industry's website.
Unique Student Identifier (USI)*
Section 2 - Employment Details
Current Employer
Current Position
Phone Number
Section 3 - Language and Cultural Diversity
Are you of Aboriginal origin?*

YesNo
Are you of Torres Strait Islander origin?*

YesNo
Were you born in Australia?*

YesNo
If you were not born in Australia, please specify:
Are you an Australian citizen?*

YesNo
If you are not an Australian Citizen, please specify:
Do you speak a language other than English at home?*

No, English OnlyYes
If you do you speak a language other than English at home, please specify
How well do you speak English?

Very WellWellNot WellNot at all
Section 4 - Disability
Do you consider that you have a disability, impairment or long-term condition? (You may indicate more than one area)

VisionMental IllnessHearing/DeafLearningPhysicalAcquired Brain ImpairmentMedical ConditionIntellectualOther
Section 5 - Prior Education / Training
What is your highest completed school level?

Completed Year 12Completed Year 11Completed Year 10Completed Year 9 or equivalentCompleted Year 8 or lowerDid not go to school
In which year did you complete that school level?
Are you still attending secondary school?

YesNo
Have you successfully completed any of the following qualifications? (Please tick ALL applicable boxes)

Bachelor Degree or Higher DegreeAdvanced Diploma or Associate DegreeDiploma (or Associate Diploma)Certificate IV or Advanced Certificate / TechnicianCertificate III (or Trade Certificate)Certificate IICertificate ICertificates other than listed
Section 6 - Employment
Of the following categories, which best describe your current employment status?

Full time employeePart time employeeSelf employed - not employing othersEmployerEmployed - unpaid worker in a family businessUnemployed - seeking part-time workUnemployed - seeking full-time workNot employed - not seeking employment
Section 7 - Study Reason
Of the following categories, which best describes your main reason for undertaking this course?

To get a jobTo start my own businessTo get a better job or promotionExtra skills for my jobFor personal interest or self developmentTo develop my existing businessTo try for a different career working with peopleTo get into another course of studyIt was a requirement of my jobOther reasons
Section 8: Health and Previous Experience in Body-oriented Modalities
Of the following categories, tick which ones are relevant:*

Pilates experienceDance/Movement/Martial Art backgroundUnder care of health practitioner for injury affecting participation in movement during courseOther illness that may affect participation in any aspect of the courseOther Body-oriented Modalities
Section 10 - Declaration and Permission
By signing electronically below:

I certify that all details provided on these forms are correct.

I understand that information contained in this form may be provided to government agencies for statistical purpose use.

I agree to pay the required deposit fee and scheduled payments to the course provider.

I grant Tensegrity Training the right to take and or use photographs/videos of me in connection with my participation in the above course. I agree that Tensegrity Training may use such photographs/videos for any lawful purpose, for example such purposes as education, training, publicity, illustrations, advertising and web content.

I also agree that Tensegrity Training may:

i. use any written feedback I provide for promotional and marketing purposes
ii. contact me to promote their courses
Ensure that you have read the Student and Partner Organisation Agreement.
*

I confirm that I have read and agree to the terms and conditions of the legally binding Student and Partner Organisation Agreement (linked above)
Electronic Signature*
Date Signed*

DayMonthYear
Parent / Guardian (required if under the age of 18)
Parent / Guardian Date Signed

DayMonthYear
When you click on the "Submit" button below, you will be sent to our payment page to

complete the payment of the $200 non-refundable enrolment fee

(which is a separate fee to the prescribed Course Fee).
Should be Empty:

Advanced Clinical Training Enrolment Form

Section 1 - Personal Details

Section 2 - Employment Details

Section 3 - Language and Cultural Diversity

Section 4 - Disability

Section 5 - Prior Education / Training

Section 6 - Employment

Section 7 - Study Reason

Section 8: Health and Previous Experience in Body-oriented Modalities

Section 10 - Declaration and Permission