IHNA

^*Title

^* First Name (Legal Given Name)

Family Name (Legal Family Name)

^* Date of Birth (dd-mm-yyyy)

^* Email

Middle Name (Legal Middle Name)

^* Mobile

^*Student Type?

DomesticInternationalOffshore

^Upload Photo ID(Driving licence, Key Pass etc) [Accepted Files: (jpg,jpeg,doc,pdf,txt,xls,xlsx,ppt,pptx,docx)]*

PERMANENT ADDRESS

Building/Property Name

Flat/Unit Number

^*Street Number

^*Street Name

^*Suburb, Locality or Town

^*Country

^*State/Territory

^*Zip / Postal Code

COURSE DETAILS

Course : Provide basic emergency life support

Course Delivery Mode : Blended

^*Campus

^*Course Intake

UNIQUE STUDENT IDENTIFIER (USI)

USI Status

USI

If you would like us (IHNA) 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 Australian Government USI. 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.

Personal Identification Details

Town or City of Birth (Name of the Australian or overseas town or city where you were born)

State

Licence Number

Medicare card number

Individual reference number (next to your name on Medicare card)

Card colour: (select which applies)

GreenYellowBlue

Expiry date of card (mm-yyyy)

Expiry date of card (dd-mm-yyyy)

Passport number

Country of issue

State/Territory

Stock number

Acquisition date (dd-mm-yyyy)

Immicard Number

Document Type (ID)

Country of Birth

I have read and I consent to the collection, use and disclosure of my personal information (which may include sensitive information) pursuant to the information detailed at Australian Government USI, and NCVER policies, procedures and protocols published on NCVER’s website.

DISABILITY

^*Do you consider yourself to have a disability?

YesNo

^*Disablility

^*Disability Effective From Date

^*Disability Effective To Date

EMPLOYMENT

^*Study Reason

CONSENT

I consent to receive marketing materials such as emails from IHNA for the purpose of notifying me of IHNA 's offers for other courses etc.

I have read and understood the Student Handbook and the Course Brochure (available at www.ihna.edu.au).

I have read and understood the Privacy Policy.

I have read and understood the USI information.

Feedback

Can you suggest any improvements to our pre-enrolment information, application/enrolment process?

*Title

* First Name (Legal Given Name)