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STUDENT REGISTRATION FORM

Personal Information

First Name^*

Last Name^*

Preferred name

Gender^*

Date of Birth^*

Street Address^*

Suburb^*

State^*

Country^*

Post Code^*

Phone Number^*

Personal Email Address^*

Emergency Contact Name^*

Emergency Phone Number^*

Study Centre

Which Study Centre would you like to use? (If applicable)

How did you hear about the Uni Hub^*

What best describes the support you would like from the Uni Hub? Tick all the apply^*

Enrolment Help Space to Study Academic Skills Access to computer/printer/internet Mentorship/Cultural support Wellbeing support Collaborative learning environment Other

If other, please specify

How far do you travel to access the Uni Hub?^*

Do you have a disAbility?^*

What language do you speak at home?^*

If other, please specify

Are you of Aboriginal or Torres Strait Islander Heritage?^*

Has any member of your immediate family completed a University degree?^*

What is the highest level of education you have completed?^*

Academic Details

Unique Student Identifier (USI)^*

You can get or create your USI here - https://www.usi.gov.au/students/get-a-usi

Expected Graduation Year

University (Provider)^*

If other, please provide details

University Provider Code

Course^*

If Other, provide Course/Degree info here:

Course Code

Student ID^*

Student Email^*

Type of Study^*

Mode of Study^*

Level of Study^*

Year level of Study

Declaration

Please print name^*

The purposes for which Uni Hub Spencer Gulf collects student registration information – including level of study, enrolling institution and other course information – includes to disclose this information to the Commonwealth Department of Education, Skills and Employment (the Department) for purposes of the administration of the Regional University Centres Program and the Higher Education Support Act 2003. This extends to, but is not limited to, assessing whether the Program is meeting its objectives, and developing higher education policy.

The Department manages information it collects in accordance with the Privacy Act 1988. For information on the Department’s privacy policy, including information on how the Department handles personal information, how you can access or correct personal information, or how to make a complaint, go to https://www.dese.gov.au/privacy.

I have read and understand the Declaration above.

Declaration Date^*

STUDENT REGISTRATION FORM

Personal Information

Academic Details

Declaration

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