Enrolment form

Please fill in the form below to enrol.

Student details
Family name:
Given names:
Street address:
Suburb/city:
State (Aust.):
Postcode:
Country:
Ph (H):
Ph (W):
Phone (mobile):
Email:
Occupation:
Date of birth:
Gender:	male female
Next of Kin:	Surname First name
	Mobile B/hrs A/hrs
	Email
Disabilities (if any):
How did you hear about ATA? You may tick more than one box.	Internet Newspaper/magazine Recommended by friend/relative Recommended by an education agent, Name please Other, Please explain how
Overseas students
Country of citizenship:	Country of birth
Passport number:	Country of issue:

Enrolment details
Are you claiming Austudy/youth Allowance/abstudy?	yes no
Do you identify with one of the following groups?	yes no
Aboriginal?	yes no
Torres Strait Islander?	yes no
Aboriginal and Torres Strait Islander?	yes no

Are you wanting to apply for an RPL?	yes (if yes please download the Application Manual for RPL (Recognition of Prior Learning) no

Are you enrolling in a Certificate IV or Diploma course?
Name of course you are enrolling in:
Course code:

If you are enrolling in Cert IV or Diploma please name each subject and date that you would like to start studying first. If you are enrolling in single subjects please name each subject and the date that you will be attending.
Subject name:	Date of attendance:
Subject name:	Date of attendance:
Subject name:	Date of attendance:
Subject name:	Date of attendance:
Subject name:	Date of attendance:

Payment Details
If seeking exemptions, please contact the College for a separate exemption form. Enrolments cannot be processed without a valid credit card number. If paying by another payment method, please complete our non-secure form and mail it to us with payment. EFTPOS payments cannot be processed over the internet.
Card type:
Card number:
Expiry date:	month year
Amount to be debited:	$AUD

Declaration: I declare that the information I have supplied on this form is, to the best of my understanding and belief, complete and correct. I understand that the giving of false or incomplete information is illegal, and that I may be prosecuted under Australia's laws and statutes.
	By checking this box you are agreeing to the policies and conditions of the Academy of Therapeutic Arts. And that you have read and agree with the Student Refund Policy.
	I have read and I accept the Academy of Therapeutic Arts policies as the conditions of my enrolment.
	I release and hold harmless the Academy of Therapeutic Arts, its principals, staff, servants and agents in respect to any property loss or personal injury that I may sustain whilst participating in my course or attending ATA howsoever caused.
Applicant's name: