ADAS Training Student Enrollment Form Unique Student Identifier Number Personal Details Family Name (Surname) DOB Sex Male: Female: Residential Address Email Emergency Contact Detail (Name and Phone no.) Given Name Countary Of Birth Nationality Postal Address Phone AVETMISS Data Are you Aboriginal or Torres Strait Islander? No Yes(Aboriginal) Yes(Torres Strait Islander) Do you speak a language other than English? No Yes(language) *If yes, how well do you speak English? Not at all Not well Well Very well Do you consider yourself to have a disability, impairment or long term condition? No Yes if yes, tick all that apply Hearing/Deaf Physical Intellectual Learning Mental Illness Acquired Brain Impairment Vision Medical Condition Other What is your highest school level completed? Completed Year 12 Completed Year 11 Completed Year 1 Completed Year 9 Completed 8 or below Did not got to school Still Attending School completion year Have you completed any additional Qualifications? No Yes if yes, tick all that apply Bachelor or higher Degree Advanced Diploma/Associate Degree Diploma (or associate) Certificate IV Certificate III Certificate II Certificate Other Which Best describes your current employment status? Full time employee Part time employee Self employed/sole employee Employer Employed–unpaid worker in family business Unemployed–seeking full time Unemployed seeking part time Not employed–not seeing employment Why are you enrolling to study? 01 To get a job 02 To develop my existing business 03 To start my own business 04 To try for a different career 05 To get a better job or promotion 06 Requirement of my job 07 I wanted extra skills for my job 08 To get into another course of study 09 Other 10 Personal interest or self development Enrolment Details ADAS Part 1 / Aquaculture (circle) Cost:$6500 Commencement Date: (4 weeks) Pre requisites AS 2299 Commercial Medical Date of issue: Recreational Cert + 10 Logged dives Date of issue: First Aid Qualification Date of issue: Oxygen Administration Qualification Date of issue: ADAS Part 2 Cost:$6500 Commencement Date: (4 weeks) Pre requisites AS 2299 Commercial Medical Date of issue: ADAS Part 1 Date of issue: First Aid Qualification Date of issue: Oxygen Administration Qualification Date of issue: ADAS Part 1 & 2 Cost:$13000 Commencement Date: (8 weeks) Pre requisites AS 2299 Commercial Medical Date of issue: Recreational Cert + 10 Logged dives Date of issue: First Aid Qualification Date of issue: Oxygen Administration Qualification Date of issue: ADAS Onshore Supervisor (Part 2) Cost:$3000 Commencement Date: (2 weeks) Pre requisites ADAS Diver Card Number: Expiry Date: Level: First Aid Qualification Date of issue: Oxygen Administration Qualification Date of issue: Appropriate logged bottom time (SSBA) Estimate of bottom time: Letter of recommendation from employer ADAS Diver Medic Technician (FULL) Cost:$2750 Commencement Date: (2 weeks) Pre requisites ADAS Diver Card Number: Expiry Date: Level: First Aid Qualification Date of issue: AS 2299 Commercial Medica Date of issue: Appropriate logged bottom time (SSBA) Date of issue: ADAS Diver Medic Technician(REFRESHER) Commencement Date: (5 weeks) Cost:$1850 $1500(bring a friend) $1200 (4 or more) Pre requisites ADAS Diver Card Number: Expiry Date: Level: First Aid Qualification Date of issue: To secure your place on your selected course, a non refundable* deposit of $1200 is required (DMT Refresher $500). Please pay via Funds transfer with the following details & your name as your reference:BSB:105-036 Account Number: 093561740 Account Name: Vebron Holdings Receipt No:By signing below I make the following declaration: the details listed here are correct and I understand the amount and timing of fees to be paid as set out by the UTCSA Enrolment guidance & fee payment protection document. I also understand that the fees listed on this page do not include certification fees or extra training fees. *Deposit refundable on certain conditions. Signed: Print Name: Date OFFICE USE ONLY Handbook & Student Brief Deposit Received Enrolment Processed Booking confirmed