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Course Registration Form
*
1.
First Name
(Required.)
2.
Middle Name
*
3.
Last Name
(Required.)
*
4.
Date of Birth
(Required.)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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16
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20
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22
23
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31
*
5.
Gender
(Required.)
Female
Male
Neutral
*
6.
Address
(Required.)
Address
*
Address 2
City/Town
*
State/Province
ZIP/Postal Code
*
Country
Email Address
*
Phone Number
*
7.
Organisation name
8.
Organisation email
9.
Organisation phone
*
10.
Course name
(Required.)
Building Inclusive Communities full course
BIC Policy & Legislation
BIC Supported Decision Making
BIC Community Connections
BIC Collaboration
Disability Responsiveness
Cultural Responsiveness
Wellbeing, Resilience and Self-care
Engagement Skills
*
11.
Do you have access to a computer and high speed internet
(Required.)
Yes
No
Other (please specify)
12.
Do you have any questions or concerns about the Course?
13.
Are you paying the Course fee, if any, or your employer?
14.
If your employer is funding your Course please name the person who authorised this.
By submitting this form you verify that the information you have provided is true and correct.
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