2019 ENROLMENT FORM 
MHCC Learning & Development

RTO No. 91296
ABN 59 279 168 647

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This training is subsidised by the NSW Government. For up to date information about Smart and Skilled please go to https://smartandskilled.nsw.gov.au or call 1300 772 104.

You must be able to TICK ALL of the following to be eligible:
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Fee Categories
Please select ONE fee category option
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Concession Fee

If you selected concession, please tell us your Benefit / Allowance type:
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NOTE:  The student fees for enrolling in a full qualification may be reduced if Credit Transfer is granted for one or more units of competency.  The eligibility for concession or exemption is assessed at enrolment and cannot be adjusted after enrolment.

Full refund for student fees will be allowed if withdrawal in writing is received by MHCC before the course start date.  For further details, please refer to the Participant Handbook.

Fee Exemption
Please select ONE option
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Please upload - Disability Support Pension or a certificate from a medical practitioner (if necessary) 
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Privacy Statement & Student Declaration

Privacy Notice

Under the Data Provision Requirements 2012, the Mental Health Coordinating Council (MHCC) is required to collect personal information (information or an opinion about me*), collected from me, my parent or guardian, such as my name, Unique Student Identifier, date of birth, contact details, training outcomes and performance, sensitive personal information (including my ethnicity or health information) and other enrolment and training activity-related information (together Personal Information) and disclose that Personal Information to the National Centre for Vocational Education Research Ltd (NCVER).

* In this context 'opinion' means any information that MHCC gathers and/or uses for training, assessment, enrolment and administration only.   

Your Personal Information (including the personal information contained on this enrolment form and your training activity data) may be used or disclosed by MHCC for statistical, administrative, regulatory and research purposes. MHCC may disclose your Personal Information for these purposes to third parties, including:

·         School - if you are a secondary student undertaking VET, including a school-based apprenticeship or traineeship;

·         Employer - if you are enrolled in training paid by your employer;

·         Commonwealth and State or Territory government departments (including the NSW Department of Industry – the Department) and authorised agencies;

·         NCVER;

·         Organisations conducting student surveys; and

·         Researchers.

Personal Information disclosed to NCVER may be used or disclosed by NCVER for the following purposes:

·         Issuing a VET statement of attainment or VET qualification, and 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 an NCVER student survey which may be administered by a government department, an NCVER employee, agent, third party contractor or other authorised agencies. 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).

The Department may disclose my Personal Information to other Australian government agencies, including those located in States and Territories outside New South Wales.

The above government agencies may use my Personal Information for any purpose relating to the exercise of their government functions, including but not limited to the evaluation and assessment of my training, the determination of my eligibility to receive subsided training or for any Fee Exemptions or Concessions. My Personal Information may also be disclosed to other third parties if required by law.

I also acknowledge and agree that the Department may contact me by telephone, email or post during or after I have ceased subsided training with MHCC, for the purposes of evaluating and assessing my subsidised training. 

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.

STUDENT SIGNATURE (Digital)
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Date
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Unique Student Identifier (USI)


From 1 January 2015, MHCC can be prevented from issuing you with a nationally recognised VET qualification or statement of attainment when you complete your course if you do not have a Unique Student Identifier (USI). In addition, we are required to include your USI in the data we submit to NCVER. If you have not yet obtained a USI you can apply for it directly at http://www.usi.gov.au/create-your-USI/ on computer or mobile device.

If you would like MHCC to apply for a USI on your behalf you must authorise us to do so and declare that you have read the privacy information at question 10.

1.    Enter your Unique Student Identifier (if you already have one) Unique Student Identifier (USI)   

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Course Details

2.    a) Which qualification are you enrolling in?

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b) Training Location:
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c) Student Support Will you need any study support or assistance during training or assessment?  If yes, please specify.


**Please note: you will be asked to complete a Language, Literacy, and Numeracy (LLN) should you be accepted into a qualification. 

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d) Will you request for Credit Transfer? 

If yes, please attach certified copies of certificates and transcripts you may hold.  As part of the national training system, it is possible to gain credit for units of competency that were completed as part of another qualification.  An assessor will review your transcript to see if you can be provided credit in one or more unit/s of competency to attain the qualification you are enrolling in.

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Please upload your transcripts to be considered fora credit transfer. If you are wanting to apply for RPL, please contact MHCC for further information or email training@mhcc.org.au

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Personal Details * Please write the name that you used when you applied for your Unique Student Identifier (USI), including any middle names. If you do not yet have a USI and want MHCC to apply for a USI on your behalf, you must write your name, including any middle names, exactly as written in the identity document you choose to use for this purpose.

3. a) Personal Details*

Title

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Gender
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Family name (surname)
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Given names
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Enter your birth date

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b) Enter your contact details


Home phone:

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Work phone:

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Mobile:
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E-mail Address:
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c) What is the address of your usual residence?

Please provide the physical address (street number and name not post office box). If you are from a rural area use the address from your state, territory or rural property as your residential street address. Building/property name is the official place name or common usage name for an address site.


Building/property name:

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Flat/unit details:
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Street or lot number (e.g. 205 or Lot 118)
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Street name:
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Suburb, locality or town:
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State/territory
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Postcode:
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d) please attach your Certified ID and other applicable documentary evidence 

Alternatively, you may email to paul.v@mhcc.org.au or training@mhcc.org.au or post to PO Box 668 Rozelle, 2039

For further information phone Paul Vescio 02 9555 8388 ext. 106.

It is a requirement that all applicants provide a certified copy of photo identification such as driver licence or passport. Copied documents may be certified by a person who is authorised as a witness for statutory declarations which includes: JPs, pharmacists, doctors, nurses, optometrists, police officers, Australia Post officer, teachers. For a full list go to:

http://www.ag.gov.au/Publications/Pages/Statutorydeclarationsignatorylist.aspx

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Certified ID
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Emergency Contact
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Surname
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First Name
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E-mail Address
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Contact Number
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Language and cultural diversity

4. a) In which country were you born?
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b) What is your citizenship status?
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c) Do you speak a language other than English at home?
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- If you selected (Yes, other) please indicate, which language you speak most often.
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d) How well do you speak English? 
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e) Are you Aboriginal or Torres Strait Islander origin?
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Disability

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

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b) If you indicated the presence of a disability, impairment or long-term condition, please select the area(s) in the following list: (You may indicate more than one area) Please refer to the Disability supplement for an explanation of the following disabilities.
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Schooling

6.    a) What is your highest COMPLETED school level? (Tick ONE box only)

If you are currently enrolled in secondary education, the Highest school level completed refers to the highest school level you have actually completed and not the level you are currently undertaking. For example, if you are currently in Year 10 the Highest school level completed is Year 9.

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b) Are you still enrolled in secondary or senior secondary education?
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Previous qualifications achieved

7.    a) Have you SUCCESSFULLY completed any of the qualifications listed in question?

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b) If YES, tick ANY applicable boxes.
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Employment

8. a) Who is your employer?

Organisation name:
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Position title: 
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b) Of the following categories, which BEST describes your current employment status? (Tick ONE box only) For casual, seasonal, contract and shift work, use the current number of hours worked per week to determine whether full time (35 hours or more per week) or part-time employed (less than 35 hours per week).
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- How many hours per week to you work?
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9.    Of the following categories, select the one which BEST describes the main reason you are undertaking this course/traineeship/apprenticeship (Tick ONE box only)


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Please attach a relevant mental health or peer work job description. 

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10. Supervisor Endorsement

Completed by students enrolling in the Certificate IV in Mental Health Peer Work


Please ask your supervisor to fill out this section. This section is a part of the Selection Criteria and must be filled out. Application forms submitted without this information will not be assessed. MHCC's CHC43515 Certificate IV in Mental Health Peer Work is customised for people working in identified consumer or carer peer work roles. 


A number of assessments include workplace tasks or documentation. To ensure you are equipped to successfully complete work-based assessments, we ask that your supervisor tick (for Yes) if your organisation will provide you with workplace support.

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I confirm that I have read the Supervisor Handbook http://www.mhcc.org.au/media/46560/certivmhpw-supervisor-handbook.pdf and that I endorse the applicant to study the course and I agree to support the applicant to:

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(Tick those that apply)
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Supervisors Name
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Position Title 
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Organisation Name
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Contact Number
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Email
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Supervisor's Signature
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Date
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11. Application for Unique Student Identifier (USI)
If you would like MHCC to apply for a USI on your behalf you must authorise us to do so and declare that you have read the privacy information at <https://www.usi.gov.au/documents/privacy-notice-when-rto-applies-their-behalf>. You must also provide some additional information as noted at the end of this form so that we can apply for a USI on your behalf.

I (name)
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authorise Mental Health Coordinating Council to apply pursuant to sub-section 9(2) of the Student Identifiers Act 2014, for a USI on my behalf. 
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Town/City of Birth - (please write the name of the Australian or overseas town or city where you were born)

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a) Australian Drivers Licence

State:
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Licence Number:
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b) Medicare Card Number:
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Individual reference number (next to your name on Medicare card):
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Medicare Card colour: (Select which applies)
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Medicare Card Date:
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c) Australian Passport number:
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d) Non-Australian Passport number (with Australian Visa):
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Country of Issue
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e) Immicard Number: 
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Citizenship Certificate Stock number:
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Citizenship Certificate Stock number - Acquisition date
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l We will also need to verify your identity to create your USI.

Please provide details for one of the forms of identity below (A to G).  Alternatively, you can provide a certified copy of the ID document instead of recording the information. 

Please ensure that the name written in ‘Personal Details’ section is exactly the same as written in the document you provide below.

In accordance with section 11 of the Student Identifiers Act 2014, MHCC will securely destroy personal information which we collect from individuals solely for the purpose of applying for a USI.

Certified copy of ID, relating to USI
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Assessment Policy

12.    MHCC Assessment Policy

Submitting assessments 6 months overdue without an approved extension or a third resubmission

MHCC Member

$50

Non-Member

$50

Re-enrolling to submit assessment when already withdrawn from the course

$125

$135

Assessment costs are included in the qualification fees.  An assessment cost only applies if a participant has already been withdrawn from a course or if their assessment task was not submitted 6 months after the due date and no request for extension was applied for or the unit has been marked Not Yet Competent after two resubmissions and they wish to redo the assessment for the third time.

 

Disclaimer: MHCC reserves the right to discontinue/cancel or vary course and assessment at its discretion. 

13.    Check List / Handbook and other

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Disability supplement

Introduction

The purpose of the Disability supplement is to provide additional information to assist with answering the disability question.

If you indicated the presence of a disability, impairment or long-term condition, please select the area(s) in the following list:


Disability in this context does not include short-term disabling health conditions such as a fractured leg, influenza, or corrected physical conditions such as impaired vision managed by wearing glasses or lenses.

Hearing/deaf

Hearing impairment is used to refer to a person who has an acquired mild, moderate, severe or profound hearing loss after learning to speak, communicates orally and maximises residual hearing with the assistance of amplification. A person who is deaf has a severe or profound hearing loss from, at, or near birth and mainly relies upon vision to communicate, whether through lip reading, gestures, cued speech, finger spelling and/or sign language.

Physical

A physical disability affects the mobility or dexterity of a person and may include a total or partial loss of a part of the body. A physical disability may have existed since birth or may be the result of an accident, illness, or injury suffered later in life; for example, amputation, arthritis, cerebral palsy, multiple sclerosis, muscular dystrophy, paraplegia, quadriplegia or post-polio syndrome.

Intellectual

In general, the term intellectual disability is used to refer to low general intellectual functioning and difficulties in adaptive behaviour, both of which conditions were manifested before the person reached the age of 18. It may result from infection before or after birth, trauma during birth, or illness.

Learning

A general term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. These disorders are intrinsic to the individual, presumed to be due to central nervous system dysfunction, and may occur across the life span. Problems in self-regulatory behaviours, social perception, and social interaction may exist with learning disabilities but do not by themselves constitute a learning disability.

 

Mental illness

Mental illness refers to a cluster of psychological and physiological symptoms that cause a person suffering or distress and which represent a departure from a person’s usual pattern and level of functioning.

Acquired brain impairment

Acquired brain impairment is injury to the brain that results in deterioration in cognitive, physical, emotional or independent functioning. Acquired brain impairment can occur as a result of trauma, hypoxia, infection, tumour, accidents, violence, substance abuse, degenerative neurological diseases or stroke. These impairments may be either temporary or permanent and cause partial or total disability or psychosocial maladjustment.

Vision

This covers a partial loss of sight causing difficulties in seeing, up to and including blindness. This may be present from birth or acquired as a result of disease, illness or injury.

Medical condition

Medical condition is a temporary or permanent condition that may be hereditary, genetically acquired or of unknown origin. The condition may not be obvious or readily identifiable, yet may be mildly or severely debilitating and result in fluctuating levels of wellness and sickness, and/or periods of hospitalisation; for example, HIV/AIDS, cancer, chronic fatigue syndrome, Chronic disease, cystic fibrosis, asthma or diabetes.

Other

A disability, impairment or long-term condition which is not suitably described by one or several disability types in combination. Autism spectrum disorders are reported under this category.