Dementia Essentials Enrolment Form

Dementia Essentials - CHCAGE011 - Face to face

You are enrolling in:

Dementia Essentials: CHCAGE011 Provide support to people living with dementia.

Before you enrol please ensure you understand the:

Course requirements
Duration and delivery requirements
Assessment/completion requirements
Outcome of the course

Please refer to the following documents for details of this course

Accredited Courses Participant Handbook

Dementia Essentials Participant Course Guide

You are enrolling in:
Dementia Essentials - CHCAGE011 Provide support to people living with dementia

Personal Information

Enter the name used for your USI, including all middle names.

Please complete your personal information

Title

First Name

Single Name Indicator

Tick this box if you are legally known by a single name

Middle Name

Surname

Date of Birth

Gender

Residential Address

Please provide your usual physical home address using the Address Lookup box - enter street number, street name, street type (street/road/avenue etc) and choose the correct address from the options given. Do not use a PO Box address. Do not use a temporary address. If your address doesn’t come up, please enter it manually using the “click here to enter address manually” option.

Address - Home - Lookup

Address - Home - Unit/Flat Number

Address - Home - Street/Lot number

Address - Home - Street Name

Address - Home - Suburb

Address - Home - Post Code

Address - Home - State

Address - Home - Country

Postal Address

My postal address is DIFFERENT to my home address

Yes

Postal address

Postal address - Suburb

Postal address - State

Postal address - Post Code

Contact Details

Home Phone number

Mobile Number

E-mail Address

Emergency Contact Details

Name

Relationship

Phone

Mobile

Unique Student Identifier

From 1 Jan 2015, Dementia Australia cannot issue a nationally recognised VET qualification or statement of attainment without a valid Unique student identifier. Your USI must also be reported to NCVER.

If you have not yet obtained a USI you can apply for it directly at https://www.usi.gov.au/students/get-a-usi on a computer or mobile device.

Do you have a Unique Student Identifier?

Please enter your Unique Student Identifier

Employment Details

Employer Name

[Home] Address -

Lookup

Manual Entry

Workplace address - Lookup

[Home] Address - Street Address 1

[Home] Address - Street Address 2

Unit/Flat Number

Street Number

Street

Suburb

State

Post Code

Position

Government Data Collection Requirements

In which country where you born?

Please specify the language most often spoken at home

Are you of Aboriginal or Torres Strait Islander origin?

What is your highest COMPLETED school level?

In which year did you complete that school level?

Are you still enrolled in secondary or senior secondary education?

Have you SUCCESSFULLY completed any of the following qualifications? (You can select multiple)

Of the following categories, which BEST describes your current employment status?

Of the following categories, select the one which BEST describes your main reason for undertaking this course?

Do you consider yourself to have a disability, impairment or long-term condition?

Not Stated

Yes

If you indicated the presence of a disability, impairment or long-term condition, please select the areas in the following list: (You may indicate one or more areas)

Pre-Training Review - Language Literacy and Numeracy

Registered training organisations must complete a pre‑training assessment to ensure you have the language, literacy and numeracy skills required. Your application is reviewed to confirm you have the resources and support to complete the course.

If you have any questions about this requirement, please do not hesitate to contact Dementia Australia on 1300 DEMENTIA.

Do you have any areas in literacy that you are concerned about?

Do you have any additional support requirements or concerns you would like to discuss with us before you commence the unit?

Assistance

Do you require additional assistance / consideration?

If "yes" - is it due to:

Disability

Learning

Medical Condition

Other

What setting do you work in?

Employment setting

Employment Eligibility

Eligible participants must be working with people living with dementia in a professional capacity to complete this program.

Are you currently working in a professional capacity supporting people living with dementia?

What is your current job role?

If you selected other, what is your job role?

Eligibility Requirement

If you say No to any questions, contact Dementia Australia directly on 1300 DEMENTIA (1300 336 368) or email

educationservices@dementia.org.au

Are you employed as a health care worker in Australia ?

Are you working in a role where you are supporting at least two people living with Dementia ?

Do you have access to the individualised care plans and other relevant documentation relating to the care of people living with Dementia ?

Do you have access to your Organisation policies and procedures ?

Do you have access to a computer and good computer skills ?

Terms & Conditions

PRIVACY NOTICE AND STUDENT DECLARATION

Privacy notice

Under the Data Provision Requirements 2020, Dementia Australia is required to collect personal information about you and to disclose that personal information to the National Centre for Vocational Education Research Ltd (NCVER).

Your personal information (including the personal information contained on this enrolment form), may be used or disclosed by Dementia Australia for statistical, administrative, regulatory and research purposes. Dementia Australia may disclose your personal information for these purposes to:

Commonwealth and State or Territory government departments and authorised agencies; and
NCVER.

Personal information that has been disclosed to NCVER may be used or disclosed by NCVER for the following purposes:

populating authenticated VET transcripts;
facilitating statistics and research relating to education, including surveys and data linkage;
pre-populating RTO student enrolment forms;
understanding how the VET market operates, for policy, workforce planning and consumer information; and
administering VET, including program administration, regulation, monitoring and evaluation.

You may receive a student survey which may be administered by a government department or NCVER employee, agent or third party contractor or other authorised agencies. Please note you may opt out of the survey at the time of being contacted.

NCVER will collect, hold, use and disclose your personal information in accordance with the Privacy Act 1988 (Cth), the National VET Data Policy and all NCVER policies and protocols (including those published on NCVER's website at www.ncver.edu.au).

For more information about NCVER's Privacy Policy go to https://www.ncver.edu.au/privacy.

Student declaration and consent

I declare that the information I have provided to the best of my knowledge is true and correct.

I consent to the collection, use and disclosure of my personal information in accordance with the Privacy Notice above.

I declare that I completed the Pre-Training Review section of this enrolment form on my own and in the event my USI is incorrect, I authorize Dementia Australia Limited to locate it via www.usi.gov.au.

I have read and agree to the Terms & Conditions

Exclude me from all future marketing communications from Dementia Australia.

Please draw your signature in the box below...

By ticking the I Agree box above and electronically signing here you acknowledge this is equivalent to a standard handwritten signature.

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This course is currently not open for enrolments