Information Web

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-****

* ****** ****, ****** ****, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 1

Applicant’s Name: Date: How did you know about us? OFFICE USE (HELP DESK CONSULTANT)

Name:

HWSETA REG, NO: HW591PA1212477

Enrolment Form

PHASE ONE

The learner must submit the application form obtainable from the reception, together with the required documents before the closing date that will be specified for a particular learning programme

(NB): No late applications will be accepted.

PHASE TWO

All the learners who have applied will be invited to attend selection interviews (Initial diagnostic assessment). Learners who have succeeded the selection procedure will be called upon to pay a deposit of amount specified for each learning programme as a proof that the learner has enrolled as learner in MRCHE before commencing the learning programme. PHASE THREE

Registration requirement: Registrations requirements depend on the requirements specified for each learning programme. Admission is from minimum of Grade 10 -12 or Equivalent PLEASE ATTACH 2 CERTIFIED COPIES OF ID, 2 LATEST ACADEMIC, TERTIARY EDUCATIONAL RESULTS, MOTIVATIONAL LETTER & CV

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 2

LEARNER INFORMATION

Name of the college: Name of the course: Course start date: Sponsor name: Venue: Trainers/facilitators:

(1) (2) (3) LEARNER DETAILS:

Name and surname: ID no: CONTACT DETAILS:

Postal address: (work) (home) Postal code: Postal code: Telephone no: work: Home:

Fax: Cell: E-mail: Facebook Profile Name:

http://www.facebook.com/ Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 3

DEMOGRAPHIC INFORMATION:

Age: Gender: Occupation: Unemployed: Unemployed: Citizenship: City/Town: Municipality: Province: Rural/Urban Country: PARENT/GUARDIAN DETAILS:

Name and surname: ID no: CONTACT DETAILS:

Postal address: (work) (home) Postal code: Postal code: Telephone no: work: Home:

Fax: Cell:

E-mail: Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 4

Write the programme name for which you

would like to register, e.g. COMMUNITY

HEALTH CARE (see academic programme

brochure for more details)

LEARNER EDUCATION AND TRAINING BACKGROUND:

Highest qualification Obtained (grade 10, 11, 12 etc.): Highest SAQA Equivalent qualification to (grade 10, 11, and 12 etc.): Prior/previous learning experiences/skills (with regard to this learning programme): Language preference:

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 5

LANGUAGE SKILLS:

English Excellent Average Poor

Read

Writing

Speaking

HOME LANGUAGE:

1 Excellent Average Poor Read

Writing

Speaking

OTHER LANGUAGE:

2 Excellent Average Poor Read

Writing

Speaking

SPECIAL LEARNING NEEDS (State relevant disabilities or learning difficulties) SPECIFIC LEARNING NEEDS (with regards to the above mentioned disability or learning difficulties if there is any):

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 6

MOTIVATION FOR ENTERING THIS LEARNING COURSE:

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 7

FOR OFFICE USE ONLY

PERFORMANCE AND ACHIEVEMENT DURING AND AT END OF THE PROGRAMME: Assessor(s) name: (1)

(2) Assessor(s) signature: (1)

(2) FINAL ASSESSMENT:

Assessor(s) name: (1)

(2) Assessor(s) signature: (1)

(2) FOLLOW-UP ACTION Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 8

LEARNERS CONTRACT

Full names and surname of a learner - Declare, agree and undertake the following towards the MRCHE

(a) That I shall acquaint myself with the content of rules and regulations of the MRCHE that apply to the learner in general as well as to course / learning programme for which I am registering and that, for the entire duration of my study, I commit myself to fulfillment of these rules and regulations as well as to the additional rules and regulations that MRCHE may announce thereof.

(b) That failure to fulfill these rules and regulations can lead to disciplinary steps being taken, including permanent suspension from the college

(c) That I shall acquaint myself with the admission requirements of MRCHE for the course/learning programme which I am registering and shall fulfill these requirement at the commencement of academic year;

(d) No registration will take place unless a minimum amount as stated in the learning programme brochure, has been paid;

(e) That I cede and transfer to the college my rights and title in any intellectual property that I create or make in the course of study or research project that undertake or may undertake at MRCHE or that I develop with the assistance of the MRCHE equipment except where otherwise agreed;

(f) That if any exploitable intellectual property rights emanate from my studies at MRCHE and the college shall derive revenue from it; the college shall pay me a portion of the revenue in terms of the guidelines that the Chief Executive Officer of MRCHE may lay thereof.

(g) That I undertake to sign any document, whenever necessary, to cede and transfer the rights concerned;

(h) That this contract is and enforceable for the entire duration of my registration at MRCHE thereafter until I have fulfilled all obligations in terms thereof;

(i) That MRCHE is entitled to summarily cancel my registration at any time if false/incorrect information is provided to MRCHE

(j) That I indemnify MRCHE against any liability damage of whatsoever nature that I may cause while I am registered as a learner at the college, irrespective of whether liability or damage result from any performed on or the premises of the college

(k) Registration period will depend on the notional hours specified for each learning programme

(l) I am aware that I will attend classes after a specified deposit is paid

(m) No refund will be considered after 5 days of attending classes, and should a learner cancel his/her course or fail to attend his/her course.

(n) All outstanding fees must be paid in full before final assessment, failure to do so will result in the decision to delay the student from completing the assessment until the fees are settled.

(o) All learners must complete the official registration form and submit a certified copy of their identity document, two ID photos and registration requirements specified in each learning programme that the learner is registering for.

(p) Learning programme fees are payable on cash, debit order, cheque or installment basis

(q) If the learner is paying on an installment basis then his/her monthly installment must be paid on or before the (1) first day of each month.

(r) Uniforms and portable equipment are available on campus and they are not included in the school fee but are available for sale.

(s) Learning Materials are provided in a free tablet in the form of eBooks

(t) Transport to clinical/ practical, Indemnity Cover, Accommodation, Student Name Tags, Access Cards and portable nursing equipment is the learner’s own responsibility

(u) Field trips, the college will subsidize

(v) In the event that I do not complete my studies or wish to cancel my registration for whatever reason, I am fully aware that I will not be entitled to any refunds of any study or examination fees or part thereof paid by my guardian or me.

LEARNERS SIGNATURE

Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 9

PARTICULARS OF PAYMENT

Indicate the payment option below with your “signature” as well as the payment amount. Deposit into MPILO ROYALTM COLLEGE OF HEALTH EDUCATION, (NEDBANK BALFOUR PARK, ACCOUNT NUMBER: 102*******, BRANCH CODE: 151105 Reference: Student Name And Surname) may only be made if a copy of deposit slip is attached to the registration form.

DECLARATION BY PAYING PART

I do accept total responsibility for the payment of the named student’s fees to the fullest and accept that, this stands binding in me. I further agree that any failure by the student to attend lectures will not reduce my liability for the fees for the fullest programme. I understand that this contract may not be cancelled. I agree that if any instalments due here under remain unpaid for three months after the due date thereof, the whole balance will be deemed to have become due and payable in full and if attorneys are instructed to recover any amounts due, I will be liable for all costs and collection charges. Signature Date Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 10

DECLARATION BY THE LEARNER

DECLARATION AND UNDERTAKING

I declare that all the information furnished by me on this form is true and correct, and I undertake to comply with the rules, regulations and decisions of MPILO ROYALTM COLLEGE OF HEALTH EDUCATION, and any amendments thereto which may be applicable to learners in general and produces or transmits in any form or manner, whether electronically or mechanically including photocopying, recording or any other form of information storage or retrieval, any study guide, book, thesis, dissertation, article, examination paper, lecture, printed tutorial matter or any other study aids in respect of which copyright exists, unless such reproduction or transmission is done in an authorized manner. Date

Learner’s signature Tel: (011-***-**** Fax: 086-***-**** Cell: (078-***-**** 5 Beacon Road, Access City, New Doornfontein

5th Floor, Johannesburg 2094

Email: ****@*****.**.** Web: www.mrche.co.za

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Page 11

CANCELLATION POLICY ACKNOWLDGEMENT

DECLARATION AND UNDERTAKING

I fully undertake responsibility and declare that:

NB. (a) In the event that I do not complete my studies or wish to cancel my registration for whatever reason, I am fully aware that I will not be entitled to any refunds AFTER 5 DAYS OF ATTENDING CLASSES or being absent without any valid reasons and reporting.

(b) That I will be liable to pay a 20% CANCELLATION FEE on the Deposit/Tuition/Equipment fees paid should I cancel before attending classes soon after registration.

(c) Should I cancel or withdraw from the course WITHIN 5 DAYS after the course has commenced I will be charge a 50% CANCELLATION FEE ON THE DEPOSIT/TUITION/EQUIPMENT

(d)After 5 DAYS OF ATTENDING CLASSES NO REFUND WILL BE PAID.

(e) That this contract is and enforceable for the entire during of my registration at MRCHE thereafter until I have fulfilled all obligations in terms of thereof.

(f) The school will not EXCHANGE OR BUY BACK the used uniform or equipment and tablets that have been already purchased or issued.

(g) ACCOMMODATION POLICY will be applied based on the contract that the student might have entered into with the Mpilo RoyalTM College and proper measures will be followed. Date

Learner’s signature

Contact this candidate