MOUNT STREET NEIGHBOURHOOD HOUSE INC.

RECEIPT NUMBER (office use)

Reg Number A0010410M ABN: 54 013 365 747

  

ENROLMENT FORM
................................

*Please Note: Refunds will not be given unless a course is cancelled.
Term 1 2 3 4

Also Note: No student may attend a class without completing this form.
Year 2010

PRIVACY STATEMENT

The information on this form is collected only for Mount Street Neighbourhood House to identify its students for
safety and insurance purposes. It is a legal requirement for Mount Street Neighbourhood House to have the details
of all students enrolled in classes. If you do not wish to fill out this form, you would not be covered by our Public
Liability Insurance and Mount Street Neighbourhood House would be unable to permit you to undertake a course at
the House. Your personal information is only seen by the Office Staff and Tutors. It will not be disclosed to a third
party without your consent unless we are required or authorised to do so by law or other regulations. The
enrolment form is only kept for 12 months, after which time it is shredded. Our class list which only have your
name and phone number on are kept in perpetuity for insurance purposes. By filling out this form you are giving
your consent to the information to be seen by the staff members of Mount Street Neighbourhood House. You are
able to gain access to the information Mount Street holds about you and to seek correction if necessary.
Title First Name Surname
Address Postcode
Phone Number (Home) Business or Mobile
Emergency Contact Name Phone Number
Pension/Health Care Card Number
This number is required in order to obtain a course fee discount. Discounts available on most courses over 4 weeks.
Do you consent to this information being seen by Office Staff? Yes No
Name of course you are enroling in
**Please check to make sure there is a vacancy for this course (call 9803 8706) before submitting your enrolment form **
Day Time Course fee

Credit/Debit Card Card Number

Expiry date : Month Year
**A $2.00 surcharge applies for credit card payments and 50¢ for debit card payments.**
DO YOU HAVE A MEDICAL CONDITION OR PROBLEM YOU FEEL WE SHOULD KNOW ABOUT?
We aim to ensure that the facilities we provide for our courses meet the needs of all participants. If you have an
illness, injury or disability that you believe we should know about in order to meet your special needs or that the
Office Staff may need to know about in an emergency, please fill out the information below. The health information we collect from you will be used only for this purpose and will not be disclosed to any other person
without your consent. If you do not wish to provide this information, please leave this line blank.
Medical Condition
CONSENT
I consent to the staff of the Neighbourhood House seeking or where appropriate administering such emergency
treatment as is reasonably necessary. It is necessary for the tutor of your course to have access to your full
name, phone number, and other relevant details in order to ensure to that the most appropriate action to be taken
in the event of an emergency.

 

 
SIGNED______________________________________________ DATE__________________
 
Please print, SIGN and post completed form together with your credit card details, cheque or money order
made payable to :
Mount Street Neighbourhood House, 6 Mount Street, Glen Waverley Vic 3150
or fax your completed form to 9803 5923