ENROLMENT FORM

Class ID

Class Name

Day

Start Time

Fee ($)

Concession (if applicable)

Materials Cost (if applicable)

Membership (if required)

TOTAL AMOUNT DUE ($)

Name:

Post Address:

Postcode:

Home Address:

Postcode:

Home Phone:

Daytime Phone:

Fax:

Date of Birth

Sex (M/F)

Reason for
Enrolling

Career
Self Interest

How did you find out about this course?

SURVEY INFORMATION, PLEASE COMPLETE WITH ENROLMENT APPLICATION (voluntary)

In what country were you born?

What language do you speak at home?

Are you of Aboriginal or Torres Strait Island descent?    Yes    No

What best describes your current employment?

What is your highest education level achieved?

Full Time

Seeking Full Time Work

Year 10 or equivalent

Tertiary

Part Time/Casual

Seeking Part Time Work

HSC or equivalent

Post Graduate

Self Employed

Not Seeking Work

Other (Give details)

Employer

Unpaid Family Worker

Do you have a permanent or significant disability?

Yes/No

If yes, please indicate:

Do you require special assistance or wheelchair access as a result of the above disability? Yes/No

CONCESSION DETAILS

Pensioner

Card No:

Part Time Student

Student No:

Full Time  Student

Student No:

Special

Type/Reason:

CREDIT CARD DETAILS

MasterCard     Bankcard     Visa

OFFICE USE ONLY:

Card Holder’s Name:

Cash/Cheque

Credit Card No:

Expiry:

Date Paid:

Receipt No:

Card Holder’s Signature:

(This signature authorises payment for all classes listed)

PO BOX 1930, Coffs Harbour, NSW, 2450

Membership to CCCC is $5.50 per year and entitles you to a 5% discount on non-accredited courses.

You will be refunded in full if we cancel the course.

You must give five working days notice if you cancel your enrolment to receive a refund.