Diploma of Life Coaching - Enrolment Form

Personal Details

First Name:*
Last Name:*
Postal Address:*
Suburb/City:*
State:*
Postcode:*
Country:*
My postal address is different to my home address.

Postal Address:
Suburb/City:
State:
Postcode:
Country:

Telephone (BH):*
Telephone (AH):
Telephone (Mobile):
Email:*
Date of Birth:*
Gender:*	Male Female
Occupation:*

Do you require assistance with language, literacy, or numeracy?* Yes No
Do you have a disability, impairment or long term medical condition?*
Please indicate details
Will you require additional learning support?
Yes No

General Information

We are interested in your reason(s) for enrolling in the course:
For self interest/personal development To set up a counselling practice To develop my practice further To asssit in my current employment	To further my employment To get a better job or promotion It was a requirement of my job To gain entry to another course

Where did you hear about the Institute:

Where did you hear about the Institute's Website:*
Search Engine	If so, which one?
Online Education or Course Directory	If so, which one?
Online Telephone or Business Directory	If so, which one?
Other	If so, where?

Training providers are required to report various demographic information and unit and course completion details for all students. The following information ensures we can report accurate information for you and your enrolment with us.
Employment Status
What is your current employment status?*
Schooling
What is your highest COMPLETED school level?*
Name of School where highest level was achieved:*
Year Completed:*
Are you still attending secondary school?*	Yes No

Previous Qualifications
What is the highest level of education you have participated in or completed, prior to commencing this course?*
Was this qualification an:*
Language and Culture
Country of Birth:*
Current Nationality:*
How well do you speak english?*
Do you speak a language other than English at home?
Are you of Aboriginal or Torres Strait Islander origin?*
Unique Student Identifier
Under government legislation, it is now compulsory for students to provide their training provider with a Unique Student Identifier (USI). For students who may not have a USI, training providers can apply for a USI on your behalf
Do you have a Unique Student Identifier (USI)?*
If Yes, what is your USI?
If No, would you like us to apply on your behalf for a USI?
If you select No, then you are able to apply at www.usi.gov.au to request your USI. Once you have your USI, please select "Yes" in the first question above to confirm you have a USI, and then input your USI.

Please supply the following so we can apply for your USI on your behalf:
City / Town of Birth
Country of Birth
Identification Requirements - Please provide TWO ONLY of the following document details:
Australian Driver's License...
License Number
State
Australian Passport...
Passport Document Number
Medicare Card...
Card Number
Individual Reference Number
Valid to	/
Colour of Card
Australian Birth Certificate...	(Please refer to full Birth Certificate, not an extract)
Registration Number
State
Registration Date	/ /
Date Printed	/ /
Certificate Number
Citizenship Certificate...
Stock Number
Acquisition Date	/ /
ImmiCard...
ImmiCard Number
Visa with Non-Australian Passport...
Non-Australian Passport Number
Country of Issue
Certificate of Registration by Descent...
Acquisition Date	/ /
How would you like to be advised of your USI?
I understand that the above information will be used to either obtain and/or validate a Unique Student Identifier for me which is required to issue my certificate for the qualification and enables the Institute to report my progress and completion of the course.

Please select your Course and preferred Specialty Streams
Diploma of Life Coaching

with optional Specialty stream(s) in:
Executive Coaching	Business Coaching	Workplace Coaching
Health & Wellness	Career Coaching	Life Cycle Coaching

Course	Diploma of Life Coaching	Diploma with 1 Stream *	Diploma with 2 Streams *	Diploma with 3 Streams *
Reduced Upfront Payment	$3,950 (save $1,000)	$4,545 (save $1,230)	$5,140 (save $1,460)	$5,735 (save $1,415)
Distributed Monthly Payment	$275 x 18	$275 x 21	$275 x 24	$275 x 26

* Investment indicated for Specialty Streams includes GST

The Diploma of Life Coaching includes 7 compulsory practical course elements which can be completed by attending seven Skill Assessment Workshops (four 1-day workshops and three 2-day workshops). Each day is just $140. If you are unable to attend the workshops in person, these practical components can be completed by demonstrating your skills on DVD/video (cost as per seminar attendance), or having a private assessor assess your skills ($20, plus assessor fee).

The Diploma of Life Coaching also includes 7 TeleClasses.

Monthly payments can be made by Credit Card or Direct Debit.

Payment Options
	I wish to pay the Reduced Upfront Payment of $3,950
	I wish to pay Distributed Monthly Payments of $275 per month beginning on today's date, with 17 subsequent payments of the same amount, due on the same day of each following month

Payment Details
Name on Card:*
Credit Card Type:*
Credit Card Number:*
Expiry Date:*

Student Declaration and Consent

I declare that the information I have provided to the best of my knowledge is true and correct.

I have read and I agree to the terms of the Student Agreement and Privacy Notice.

I consent to the collection, use and disclosure of my personal information in accordance with the Privacy Notice.

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Life Coaching Institute (Aust) Pty Ltd

47 Baxter Street | Locked Bag 15,

Fortitude Valley QLD 4006

Contact Numbers

Diploma of Life Coaching - Enrolment Form

Personal Details

General Information

Employment Status

Schooling

Previous Qualifications

Language and Culture

Unique Student Identifier

Please select your Course and preferred Specialty Streams

Payment Options

Payment Details

Student Declaration and Consent

> Quick Links

Life Coaching Institute (Aust) Pty Ltd