Enrol

Please note this form is an expression of interest. Places in courses are not guaranteed until confirmed by Yarrunga Community Centre and payment has been received. If you would like further information about enrolling in a program at Yarrunga Community Centre visit the Enrolment Information page.

Course Information

Name of course

Please enter the course name.

Day

Please enter the day your course takes place.

Time

Please enter the time your course takes place.

Personal Information

First name

Please enter your first name.

Last name

Please enter your last name.

Contact email

Please enter your email address.

Phone number

Please enter your phone number.

Street address

Please enter your street address.

Suburb

Please enter your suburb.

State

Please enter a state.

Postcode

Please enter your postcode.

Date of birth

Please enter your date of birth.

Gender

FemaleMaleUnspecified

Please enter your gender.

Emergency contact name

Please enter an emergency contact.

Emergency contact phone number

Please enter an emergency contact phone number.

Other Information

Country of birth

Please enter your country of birth.

Are you of Aboriginal or Torres Strait Islander origin?

YesNo

Please enter if you are of Aboriginal or Torres Strait Islander origin.

Do you have a disability?

YesNo

Please indicate whether you have a disability.

Do you require a carer to attend with you?

YesNo

Please indicate whether you require a carer.

Do you have a concession card?

YesNo

Please indicate whether you have a concession card.

If yes, please enter your concession card number

Please enter your concession card number.

Please enter your concession card expiry date

Please enter you concession card expiry date.

Do you wish to become a member of Yarrunga Community Centre?

YesNo

Please indicate whether you'd like to become a member of Yarrunga Community Centre.

Would you like to provide any additional information? (eg. allergies, medical, court orders etc.)

Please enter any additional information.

How did you find out about this course?

Please indicate how you found out about this course.

Declaration

Please read the Terms and Conditions and Code of Conduct.

I have read and understood the Terms and Conditions, and acknowledge and agree to the these.

Yes

Please agree to our Terms and Conditions.

I agree to the Code of Conduct

Yes

Please agree to our Code of Conduct.

I agree that the information provided in this application for enrolment is completed and accurate

Yes

Please confirm that the information you've provided is accurate.

If there is an emergency I allow those in charge to make decisions for my safety or wellbeing, including ambulance travel, medical treatment and hospitalisation. I understand that I have to pay for all my own medical bills and expenses.

Yes

Please agree to allow us to make decisions about your health and wellbeing in case of an emergency.

I agree for photographs of me to be taken as part of my classes at Yarrunga Community Centre Inc. to be used on display boards, TV screens, web pages or CDs, brochures/posters, videos/audio, newsletters, newspaper articles or annual reports.

YesNo

Please indicate whether you allow us to photograph you for marketing purposes.

You will automatically be added to our mailing list to receive news and updates from Yarrunga Community Centre, however you have the option to unsubscribe at any time.

Enrolment Form

Course Information

Personal Information

Other Information

Declaration

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