Rehabilitation and Return to Work Coordinator Registration Form

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Student - First Name

Student - Surname

Profile - Gender

Female

Male

Prefer not to say

Student - E-mail Address

Student - Mobile Number

Emergency Contact - Name

Emergency Contact - Mobile Number

Do you have any special dietary requirements or food allergies?

If yes, please provide details:

Do you have any other needs in relation to attending this training course? E.g. access, language assistance etc.

If yes, please provide details:

Employer's Name

Employer's Phone

Employer's ABN

Billing Address

Billing E-mail Address

I understand and accept Konekt Training's cancellation policy (see below) and I certify that the information supplied is accurate.*

Cancellations must be submitted in writing.
For cancellations received 10 working days or more prior to the course commencement date, the course fee will be refunded less a 20% administrative fee.
Within 10 working days of the course, no refunds will be made although we welcome rescheduling to an alternative training date or an alternative participant (to be advised in writing). Rescheduling less than 24 hours prior to course commencement may incur a 20% administrative fee.
Konekt Training reserves the right to cancel, postpone or reschedule a course due to insufficient numbers or other unforeseen circumstances.
If Konekt Training is required to cancel a course, participants will be offered a rescheduled course or a full refund.

I understand and accept Konekt Training's information collection policy (see below) and I certify that the information supplied is accurate.*

Your personal information is collected for the purposes of course administration, statistical analysis and program evaluation.

Your information will not be used for any other purpose except as required or authorised by or under law.