Please complete the Contact Form below to register in your course.
This information is required for the funding of Adult Continuing Education Courses.
Course Name *
Phone Number *
Physical Address *
Date of Birth *
Emergency Contact (Name, Relationship, Contact No.) *
Concession Card? * Health Care CardPension CardDept. Veteran Affairs cardno concession
Indigenous descent? YesNo
Country of Birth *
Are you currently attending secondary school? * YesNo
Highest completed school level? *
Current Employment Status * Full timeEmployerSelf-employed (no employees)Unemployed-seeking full time workpart-time employeeEmployed - unpaid worker in a family businessNot Employed - not seeking employmentUnemployed - seeking part-time work
Which best describes your current or recent occupation? * ManagerProfessionalTechnician or Trade WorkerCommunityand Personal WorkerClerical and Administrative WorkerSales WorkerMachinery Operator and DriverLabourerNever EmployedOther
Industry of Current/Recent Employer * AgricultureMiningManufacturingElectricity Gas Water & Waste ServicesConstructionWholesale TradeRetail TradeAccomodationand Food ServicesTransport Postal & WarehousingInformation Media and TelecommunicationsFinancial and InsuranceReal EstateProfessional Scientific & Technical ServicesAdmin and SupportPublic Admin & SafetyEducation & TrainingHealth Care/Social AssistanceArts & RecreationOther ServicesNever employed
Do you speak a language other than English at home? * yesno
Do you consider yourself to have a disability, impairment or long term condition? * YesNo
Please provide details of Disability, Impairment or long term condition
Have you successfully completed any of the following qualifications? * Certificate 1Cert 3 or Trade CertDiploma or Associate DiplomaBachelor Degree or Higher DegreeCert 2Cert 4Advanced Diploma or Associate DegreeNone of theseOther
Main reason for undertaking this course To get a jobPersonal InterestDevelop Existing BusinessTo get a better job/promotionUpskill for current jobTo try for a career ChangeStart a businessJob requirementTo get into another course of studyOther
Do you use Facebook * YesNo
Kyneton Community & Learning Centre Inc.
A.B.N 68 752 983 345
Incorporation no. A0019409X
34 Mollison Street, Kyneton Vic 3444
(03) 5422 3433
Monday to Thursday 9am – 3pm
The Kyneton Community House welcomes everyone. We respectfully acknowledge the traditional owners and elders, past and present, of the land on which our House is situated.