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Barossa Campus
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Student Registration
Name
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First
Middle
Last
Preferred Name
Date Of Birth
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DD slash MM slash YYYY
Address
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Street Address
Address Line 2
City
State / Province / Region
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Afghanistan
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Algeria
American Samoa
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Anguilla
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Bouvet Island
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Burundi
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China
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Congo, Republic of the
Cook Islands
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Panama
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US Minor Outlying Islands
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Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
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Phone
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Are you of Aboriginal or Torres Strait Islander Heritage?
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Please Select
No
Yes - Aboriginal
Yes - Torres Strait islander
Yes - Aboriginal and Torres Strait Islander
What is the highest level of education you have completed?
Has any member of your immediate family completed a university degree?
Please Select
Yes
No
How did you hear about the Centre?
How far do you travel to access the Centre?
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Less than 10km
10-50km
50-100km
Greater than 100km
Do you have a disability?
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No
What language do you speak at home?
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English
Other
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Emergency Contact
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Name
Phone
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Emergency Medical Information
Relevant information required in the case of an emergency
CHESSN
Student Identification Number
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Unique Student Identifier (USI)
Expected Graduation date
Tertiary Provider Name
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Provider Code
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Please type 'unsure' if details are unknown
Course Name
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Course Code
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Type of Study
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Full Time
Part Time
Mode of Study
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External
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Multi-Modal
Level of Study
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Non-AQF
VET
Tertiary Preparation Program
Undergraduate
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Year Level of Study
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1st Year
2nd Year
3rd Year
4th Year
Other
What best describes the support you would like from the Centre?
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Enrollment help
Space to Study
Access to computer/printer/internet
Mentorship/Cultural Support
Academic skills
Wellbeing support
Collaborative learning enviroment
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