Private RTO Enrolment Form (Word)

MEDICATION ADMINISTRATION APPLICATION FOR ENROLMENT FORM 2015 State enterprise training act as the lead RTO to ensure all obligations regarding RTO registration standards are met including the issue of qualifications and statements of attainments that relate to the medication units. MEDECS Australia have the expertise in the area of medication administration in both community based and health settings. They employ only Registered Nurses with the required national Trainer/Assessor competencies to deliver and assess the units. The medication administration accreditation program, including delivery and assessment resources, have been designed and developed by MEDECS Australia in consultation with SET.

Checklist before submitting your enrolment form

Completed all sections

Read & understood the cancellation policy

Selected the relevant course by placing a tick in the box

Selected a final assessment session time by placing a tick in the relevant box

Section (4) filled in

Statement of Attainment provided if credit transfer sought

Nominated supervisor identified

Please note that all enrolments close by 5.00pm the Wednesday before the allocated workshop you are to attend

Medecs Australia

Postal Address: P O Box 327 Glenorchy Tasmania Australia 7010 Phone: (03) 6272 1843 Fax (03) 6272 0768 Email: [email protected] Website: www.medecs.com.au

Medication Administration Enrolment Form 2015/30.01.2015 Page 1 of 7 Instructions Please fill in all sections clearly and carefully by writing in block letters. Information requested on this form is also for national database and tracking purposes and assists in qualification issuance.

1. PERSONAL DETAILS

Title: (Please tick) Mr Ms Mrs Miss Other Family Name: Given Names: Residential Address: Post Code: Postal Address: Post Code: Phone Numbers: Home: Work: Mobile: Email: Date of Birth: Town of Birth: Gender: M F Next of Kin & Relationship: Best phone No.: Please provide your ‘Unique Student Identifier’ (USI) if you already have one or if not please provide either your Drivers License or Medicare Number. By ticking the ‘Y’ box you agree to SET obtaining it for you: Y N If you have a Unique Student Identifier please provide: O Medicare No: ( ) Exp date: Drivers Licence: R (Please put the number you are on card in the brackets)

2. MEDICATION ACCREDITATION 2015 COURSE DETAILS This enrolment is for the prerequisite unit HLTAP301B – recognise healthy body systems in a health care co ntext and the medication unit CHCCS305C – Assist clients with medication. Please note all places are allocated on a ‘first in’ basis. There is a maximum of 12/15 places in each course. I f your preferences are not available you will be allocated a place in the next available course or assessment session. You will receive a confirmation notice to confirm your enrolment details. i) Please select the course below by placing a tick in the selection box of the course required and ii) Please select preferred final assessment session time. Please tick only one preference time.

2.1 HLTAP301B – RECOGNISE HEALTHY BODIES IN A HEALTH CARE CONTEXT I would like to apply for credit transfer for HLTAP301B Yes No

If yes, please supply statement of attainment with enrolment to gain a $50.00 discount on the program fee s.

Medication Administration Enrolment Form 2015/30.01.2015 Page 2 of 7 South – Technopark – Suite 1, Main Building, Innovation Drive, Dowsing Point

Final Selection Code Workshops Assessment Box Preferred final assessment session √ √ MS12 21st & 22nd September 23rd October  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MS13 12th & 13th October 13th November  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MS14 29th & 30th October 30th November  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MS15 17th & 18th November 18th December  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm 

North – State Enterprise Training, 3/1 Blaydon Street, Kings Meadows Final Selection Code Workshops Assessment Box Preferred final assessment session √ √ MN12 14th & 15th September 19th October  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MN13 23rd & 24th September 28th October  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MN14 20th & 21st October 13th November  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MN15 4th & 5th November 9th December  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MN16 11th & 12th November 14th December  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm 

North West – Penguin Surf Club Final Selection Code Workshops Assessment Box Preferred final assessment session √ √ MNW5 10th & 11th September 12th October  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MNW6 14th & 15th October 24th November  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm  MNW7 5th & 6th November 9th December  9.00am  10.00am 11:00pm  1.00pm  2.00pm  3.00pm 

3. EMPLOYMENT DETAILS

Full-time employee Permanent part-time employee Casual employee

Name of Employer: Address: Town/Suburb: Postcode: Telephone: Fax: Workplace Supervisor: Phone:

Medication Administration Enrolment Form 2015/30.01.2015 Page 3 of 7 Supervisor Email:

Credit Card Details (if self funded)

Visa MasterCard Exp Date: ___/___

Card No:

Cardholder Name:______

Cardholder Signature:______

4. NOMINATED SUPERVISOR Eligibility criteria: (Please read criteria below before proceeding any further)  Supervisor must be an experienced staff person in a senior role to the training participant.  Supervisor has achieved the minimum required accreditation standards in medication administration and has been currently practicing those competencies for a minimum of 2 years.  Supervisor is able to mentor & co-assess the participant throughout the duration of the program and able to assist the participant in the completion of assessment activities if required.  Supervisor is able to maintain monitoring contact with the Medecs program facilitator when required.

Nominated Workplace Supervisor: ______Mobile: ______

5. CANCELLATION POLICY Medecs cancellation If in the unlikely event any program is cancelled by state enterprise training then a full refund of all fees paid up until that point will be refunded.

Participant cancellation Cancellation notice for all enrolments will be accepted up until 5.00pm on the Wednesday before the course commencement day. A cancellation fee of $35.00 will be charged in this instance. Should the enrolment be cancelled after this time full fees will be charged to the employer. Once the first day of a course commences then all enrolled participants will be charged. There are no refunds after the commencement day of each course. A self-funded participant or service organisation can receive a credit note to attend a future course based on availability of places.

6. EDUCATION

What is your highest completed school level? Year 12 Year 11 Year 10 Year 9 or equivalent Year 8 or lower Did not go to school In which year did you complete that school level?______

Medication Administration Enrolment Form 2015/30.01.2015 Page 4 of 7 Have you completed any of the following national qualifications? No Yes – Please tick below Certificate I Diploma (or Associate Diploma) Certificate II Advanced Diploma or Associate Degree Certificate III (or trade certificate) Bachelor Degree or Higher Degree Certificate IV (or Advanced Certificate/Technician) National Qualifications other than the above Year(s) Completed:______

7. LANGUAGE AND CULTURAL DIVERSITY

Are you of aboriginal or Torres Strait Islander origin? No Aboriginal Torres Strait Islander (For persons of both Aboriginal AND Torres Strait Islander origin, mark both “Yes” boxes)

Were you born in Australia? Yes No, please specify:______

Do you speak a language other than English at home? No, English only (Go to section 8) Yes, please specify:______If yes, how well do you speak English? Very Well Well Not well Not at all

8. ADDITIONAL LEARNING NEEDS Do you consider that you have a disability, impairment or long-term condition that may impact your learn ing? (You may indicate more than one area) No (Go to section 8) Yes, please specify below: Vision Hearing Physical Medical Condition Other (please specify):______Language, Literacy and Numeracy skills (LLN) The qualification or course you are enrolling in will require a foundation level of LLN skills. Please tick the box(es) below if you require additional assistance in any of these areas. If you are unsure please request a confidential LLN self-assessment form to complete. If further assistance is required we will contact you and provide details of a confidential training service.

Not Applicable Language (English) Literacy (Ability to read or write) Numeracy (Ability to understand and apply number concepts)

9. CONSENT

Individuals will be advised firstly of a ‘not yet competent result’ in the functional English, literacy & numeracy assessment. This information will then be shared with the current employer if applicable to be able to arrange suitable training support. By signing the declaration below all parties understand & agree if the situation arises, for this to occur. Personal information will be managed in accordance with the Personal Information Protection Act 2004. I understand that State Enterprise Training will not pass this information to any other party without my written permission.

Medication Administration Enrolment Form 2015/30.01.2015 Page 5 of 7 10. TRAINING AGREEMENT

The obligations of Medecs Australia / State Enterprise Training Medecs Australia is undertaking to deliver and assess you in the qualification or unit(s) outlined in section t wo of this application form. The cost and payment options for this qualification/unit are outlined in section four of this application. This information below outlines the services you are to be provided by Medecs Australia/State Enterprise Training. These include the following: . Learning resources (retained by the learner – Medecs Australia). . An educator to provide you guidance and support. This person has the necessary regulatory competencies including vocational experience at least to the level being delivered and current industry skills – Medecs Australia. . A validated assessment process to ensure the qualification you are undertaking is aligned to the national qualification criteria outlined in the relevant national training package – Medecs Australia. . A record keeping process to ensure the accuracy and integrity of all records Medecs Australia/State Enterprise Training. . A management system to ensure we are responsive to our client's needs – State Enterprise Training. Your obligations By signing this enrolment form you are agreeing to undertake the unit(s) with Medecs Australia/State Enter prise Training as outlined in section two of this application. The success of this qualification or unit(s) will be determined by your engagement. Please make sure you understand the requirements of undertaking this q ualification or unit(s) as detailed in the course outline.

11. COMMUNICATING INFORMATION

Students may from time to time receive communication from Medecs/SET in the form of emails, phone call s and/or SMS regarding their workshop schedules, postponements or changes, assessment activities, updat ed qualifications, promotions, and upcoming events. If you do not wish to receive this information please tick the box below: I do not wish to receive this communication I also authorise my employer as an authorised representative to confirm, and where applicable, supply my personal details as held by them in accordance to the organisation’s privacy policy.

12. PRIVACY STATEMENT

Personal information is collected solely for the purpose of operating as a Registered Training Organisation. We collect only personal information that is necessary for our organisation to meet its professional and lega l obligations in accordance with our SET Australian Privacy Principles (APP) Policy. The purpose of this policy and procedure is to ensure that State Enterprise Training collects, uses appropriately, and protects all perso nal information provided from all stakeholders, and ensures that it complies with the Privacy Act and Privac y Amendment Act (Enhancing Privacy Protection) Act 2012. A copy of this policy is available at www.setraini ng.com.au or please request a copy from SET Client Services Department. Phone 6343 6600 or email - client [email protected]. Personal Information is collected directly from students or authorised representatives of their employer org anisation when the State Enterprise Training Enrolment Form is completed. We may also collect personal in formation when you complete assessment activities, deal with us over the telephone or send us correspond ence (including letters, emails, faxes, social media, website enquiries and SMS). State Enterprise Training wil l take all reasonable steps to protect the personal information it holds from misuse and loss, and from unau thorised access, modification or disclosure.

Medication Administration Enrolment Form 2015/30.01.2015 Page 6 of 7 State Enterprise Training as a registered RTO, is required to provide the Commonwealth government nation al training information data (AVETMISS) with student and training activity data which will include your infor mation provided on the enrolment form. AVETMISS data (Australian Vocational Education and Training Man agement Information Statistical Standard) is a national standard for the collection and analysis of VET infor mation throughout Australia.

13. DECLARATION

I declare that I have been provided all the relevant information regarding the services to be provided by Medecs Australia/State Enterprise Training. I understand my rights and obligations in regards to this trainin g agreement. I agree to enrolment in the short courses listed overleaf as per the schedules set out by Medecs and my employer. I understand that information contained in these forms may be provided to State and Commonwealth agen cies and research organisations according to the Australian Privacy Principles and SET AAP privacy policy. I c onsent to that occurring. I certify that all details provided on these forms are correct.

Signed:______Date:______

14. ENROLMENT SIGNATURE

I have read and understood all details in this form and I certify that all information provided by me on this f orm is correct to the best of my knowledge.

Applicant Signature: ______Date: ______

Authorised Person’s Name: ______Position: ______

Authorised Person’s Signature: ______Date: ______

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