Span Enrolment Form Enrolment Form Use this form to enrol in the course of your choice. Fill it in as much as you can we will collect any othetr information when you come into Span. Have you enrolled in a course at Span previously? Yes No Course Name: Personal details: Surname: First Name: Date of Birth: Gender: Female Male Not Specified Landline: Mobile: Email Address: Suburb: Postcode: Preferred contact method: Landline Mobile Email Do you wish to receive emails regarding Span’s newsletter and brochure, etc. No Yes Emergency Contact: Emergency Contact Phone Number: Medical: Do you have a medical condition or disability that may impact on your participation at Span? Yes No Acquired brain impairment Hearing/deaf Intellectual Acquired brain impairment Mental illness Learning Acquired brain impairment Vision Other Food allergies/restrictions: Home and Community Care for Younger People Span is funded to provide support under the Home and Community Care for Younger People Program (HACC-PYP). This funding is to support special needs groups including: socially isolated; financially disadvantaged community members; people with a disability; mental illness; dementia; carers. Would you like to know if you qualify for HACC-PYP funding support? Yes No Concession Entitlement: If you are seeking a concession rate, Span must sight your current concession card. If you are posting or emailing your form, a current copy of your concession card must be attached to this form prior to course start date. Otherwise full fees will apply. How did you find out about Span? Been here before Span website Span Facebook Span newsletter Local newspaper Walking past Internet Flyers Word of mouth Other Brochure in my mail box Brochure emailed to you Privacy Statement I understand Span Community House Inc. is required to provide the Victorian Government, through the Department of Education and Training, with ACFE student and training activity data which may include information that I have provided in this enrolment form. The information is provided in accordance with the Victorian VET Student Statistical Collection Guidelines that are available at www.education.vic.gov.au/training/providers/rto/Pages/datacollection.aspx Unidentified statistical data may be used to improve the services at Span. Privacy Statement acceptance I acknowledge and agree to the terms described in this privacy statement as listed above. Photo consent: I give consent for photographs/recordings to be taken as part of my involvement with programs of Span. I also give permission for my first name to be used with these photos. Types of publicity may include social media, display boards, power point presentations, newsletters, articles or annual reports. Photo Consent Yes No Acceptance and Signature Enrollment Form acceptance I acknowledge and agree to the terms described in this privacy statement as listed above. Enrollment Form date If you have a digital copy or a photo of your signature upload it with this form. Otherwise bring it into Span when you can Send