Diploma Of Paramedical Science (Ambulance) Application Form

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Office use only
Application Rec’d:               /       / RPL fee Rec’d: $100(if applicable) Receipt No: Deposit Rec’d: $ Receipt No:
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Accepted on course:    Yes 0 Wait List 0Please complete the following details:
First name: (Preferred Name)
Surname:

Date of Birth:        /            /            Sex       M             FContact Details
Street address:
Suburb/Town: P/Code:
Day time phone: Mobile phone:
After hours phone: Email:
In case of emergency contact: Name Phone:

Please Note: Students are required to familiarize themselves with the Course prerequisites detailed in the student information pack:I, the undersigned understand and meet the aforementioned prerequisites. Additionally, to my knowledge I do not have a physical or medical condition that would preclude risk or affect my participation in this course.
Applicants Signature: Date:

application closing datesor please call (03) 99030101
1.       Of the following categories, which best describes your current employment status? (tick one box only)
Full-time employee     Part-time employee

Self employed – not employing others     Employer

Employed – unpaid family worker     Unemployed – seeking full time work

Not employed – not seeking employment     Unemployed – seeking part time work
2.       Have you successfully completed any of the following qualifications?       Yes                   No (If yes, tick any applicable boxes)
Bachelor Degree or Higher Degree         Certificate III (or Trade Certificate)

Advanced Diploma or Associate Degree         Certificate II

Diploma (or Associate Diploma)         Certificate I

Certificate IV (or Advanced Certificate/Technician)         Certificates other than the above
3.       What is your highest COMPLETED school level? (tick one box only)
Year 12         Year 11         Year 10

Year 9 or equivalent         Year 8 or lower         Did not go to school
4.       In which year did you complete that school level?
5.       Where you born in Australia? Yes            No - Please specify             ___________________________
6.       Do you speak a language other than English at home?No, English only                            Yes, other – please specify    _________________________
7.       How well do you speak English?
Very Well       Well      Not well       Not at all
8.       Are you of Aboriginal or Torres Strait Islander origin?
No         Yes, Aboriginal      Yes, Torres Strait Islander
9.       Do you consider yourself to have a disability?         Yes No If YES, then please indicate the areas of disability, impairment or long-term condition? (You may indicate more than one area)
Hearing/Deaf       Acquired Brain Impairment         Physical         Vision

Intellectual       Medical Condition         Mental Illness         Other
10.     Of the following categories, which best describes your main reason for undertaking this course? (tick one box only)
To get a job I wanted extra skills for my job

To develop my existing business To get into another course of study

To start my own business For personal interest

To try for a different career For self development

To get a better job or promotion To get a qualification

It was a requirement of my job Other reasons

Employers Details:
Company Name:
Address:
Phone:

Have you applied for RPL in relation to this course?          No        0    Yes 0 If yes, DO NOT complete this form, your RPL is your application. Our administrative staff will notify you what course requirements and costs will be.
Do you have any convictions, findings of guilt and/or pending charges against you?                                                                                           No0          Yes0Please list offences below:Ø   ____________________________________________________________Ø   ____________________________________________________________
Applicants Signature: Date:

If yes, your application will be assessed prior to acceptance into the course.
How will you be paying for this course?

Self funded Employer Sponsorship Other

Course Entry Prerequisitesv Certificate III in Non-Emergency Patient Transport (HLT30207) inclusive of Units of Competency§ HLTAMBCR1A – Deliver Basic Patient Care§ HLTAMBT2A – Transport Emergency PatientsORv Certificate IV in Basic Emergency Care (HLT41002)v Current Employment in the Non-Emergency Patient Transport Industryv A letter of endorsement from your current employerv A minimum of twelve months full-time or equivalent part-time employment totaling at least 1920 hoursv No known physical restrictions and be able to lift weights consistent with patient movement and handling requirementsv A full, unrestricted, current Victorian Drivers Licencev Attendance at a pre-selection assessment interviewv Signing a Student Agreement with Monash University Department of Community Emergency Health and Paramedic Practice.Additional requirements to accompany this Application Formv Two Passport size photographsv Deposit of $1,000.00 (payable by cheque, money order or by Credit Card over the phone) or an indication of who will be paying course fees if you are being sponsored.

Profile:Licence Number: ___________________________________
Expiry Date: _________________________
Certificate III in Non-Emergency Patient Transport (HLT30207) inclusive of Units of Competency-
HLTAMBCR1A – Deliver Basic Patient Care-           HLTAMBT2A – Transport Emergency PatientsCertificate Number: _______________________________ Date of Issue: ___________________________

Rationale: This check list is intended to support the applicant in ensuring that all relevant and required documentation and copies are included with the completed application form in readiness to be submitted.It is important to note that applications for the Diploma of Paramedical Science (Ambulance) will be considered on a first in, first served basis in combination with a pre-selection interview. Places are limited in each course and only complete applications will be considered. Incomplete forms or incomplete supply of documentation means that your application will be returned to you. This may delay your application and potentially restrict your entry into the course.DCEHPP reluctantly takes this approach, but it is necessary to ensure fairness and consistency to all valued applicants.When the course reaches the required number of participants, the remaining applications will be notified and if agreed, placed on a waiting list and in the event of a withdrawal an offer may be made for inclusion into the course.

I have NOT completed an RPL form in relation to this application
(This form should not be used in conjunction with an RPL request)

Provide two Passport size photos for ID cards (for Field Placement Tags).

Evidence of industry experience (letter from employer/s)

·         Certified copy of academic transcript of Certificate III in Non-Emergency Patient Transport

·         Certified copy drivers licence

·         National Police check

·         If currently employed in the industry, a letter of support from your employer that you will be released from duty or given appropriate rostering consideration to meet the course requirements.

If self funded please indicate where appropriate on application form

·         If employer funded, a letter from the employer detailing the level of support and payment method

·         If had a criminal conviction or court proceedings pending a letter detailing the incident

·         $1000.00 deposit enclosed with application
Please post completed application to:
Attn: Barbara MartinMonash UniversityDCEH &PPCentral & Eastern Clinical School1^st Floor Alfred Lane, Commercial RdPRAHRAN   VIC   3181

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Diploma Of Paramedical Science (Ambulance) Application Form

Main Menu

Office use only
Application Rec’d:	/ /	RPL fee Rec’d: $100(if applicable)	Receipt No:	Deposit Rec’d: $	Receipt No:

Street address:
Suburb/Town:	P/Code:
Day time phone:	Mobile phone:
After hours phone:	Email:
*In case of emergency contact: Name*		Phone:

Full-time employee		Part-time employee

Self employed – not employing others		Employer

Employed – unpaid family worker		Unemployed – seeking full time work

Not employed – not seeking employment		Unemployed – seeking part time work

Bachelor Degree or Higher Degree		Certificate III (or Trade Certificate)

Advanced Diploma or Associate Degree		Certificate II

Diploma (or Associate Diploma)		Certificate I

Certificate IV (or Advanced Certificate/Technician)		Certificates other than the above

Year 12	Year 11	Year 10

Year 9 or equivalent	Year 8 or lower	Did not go to school

Hearing/Deaf	Acquired Brain Impairment	Physical	Vision

Intellectual	Medical Condition	Mental Illness	Other

To get a job		I wanted extra skills for my job

To develop my existing business		To get into another course of study

To start my own business		For personal interest

To try for a different career		For self development

To get a better job or promotion		To get a qualification

It was a requirement of my job		Other reasons

I have NOT completed an RPL form in relation to this application (This form should not be used in conjunction with an RPL request)

Provide two Passport size photos for ID cards (for Field Placement Tags).

Evidence of industry experience (letter from employer/s)

· Certified copy of academic transcript of Certificate III in Non-Emergency Patient Transport

· Certified copy drivers licence

· National Police check

· If currently employed in the industry, a letter of support from your employer that you will be released from duty or given appropriate rostering consideration to meet the course requirements.

If self funded please indicate where appropriate on application form

· If employer funded, a letter from the employer detailing the level of support and payment method

· If had a criminal conviction or court proceedings pending a letter detailing the incident

· $1000.00 deposit enclosed with application