Course Application Form
Name
Surname Christian Name
Contact
Home Street Suburb/Town
State Postcode
Home Phone Home Email
Organisation
Please provide details on the Facility/Organisation where you work
Organisation Name Address
Phone Fax
Work Email
On what basis are you currently employed at the facility/organisation where you work?
What is the title of your current position?
Qualifications
Please indicate your formal qualifications
Other - please indicate
Eligibility

The course is available to aged care workers employed in residential, respite or home and
community care settings who have not previously completed Unit of Competency
“CHCAC15A – Provide care support which is responsive to the specific nature of dementia”
through other Commonwealth funded education programs. Previous completion of a
Certificate (III) or (IV) in Aged Care or Home and Community Care does not necessarily
preclude people from accessing this free course.

There is an expectation that all participants will undertake the assessment
component of this training in order to apply their learning in the workplace.

Note: If you are not eligible to complete this free course, places are still available on a fee
for service basis. Enquiries are welcome. According to the criteria above are you
eligible to complete this free course?
 

Dates
From the training schedule select up to (2) preferred dates that best suit your needs
Preference (1) Preference (2)
Cancellations/
Changes
All cancellations, changes of name(s) or booking difficulties, should be notified to ACSWA immediately
Other
How did you find out about Dementia Care Essentials?
Other (please describe)

Would you like your name included on our mail list and receive mail outs
or emails on progress and achievements of Dementia Care Essentials?
Do you require disability access?
 
Do you require assistance with hearing?
 
Do you require assistance with vision?
 
Do you have special dietary needs?
If so please specify.
Is English the main language you speak?
If not please specify.
 

Dementia Care Essentials has been developed in conjunction with the following partners: