This form is for the Anglicare Retirement Village Castle Hill Computer Club to enter session details for each participant. Learner Session Details for Anglicare Techmates You are completing this form on behalf of your learner. Please enter their details. "*" indicates required fields Is this Student an Existing Learner or a New learner?*Please Select ...New Learner Registration FormExisting LearnerPlease let us know if this learner has registered with us or is a brand new first time learner.New Learner Registration The New Learner Registration Form only needs to be completed once for each Learner. We need this form to create a DEX profile to be able to log sessions. Thank You!Existing Learner Session Entry This form is for Tech Mates entering the session details for their LearnersLearners Name* First Last Learner Contact Number* Gender*MaleFemaleIntersex/IndetermiateNot StatedEmail Is the Learner Continuing?YesNoUnknownPlease let us know if the Learner intends to cease being mentored so we can remove them from our listing.HiddenAddress* Street Address Address Line 2 Suburb State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenLanguage SpokenEnglishOtherDate of Birth* DD slash MM slash YYYY Is Date of Birth Real?*Real DOBEstimated DOBHiddenIndigenous Status*NeitherAboriginalTorres Strait IslanderAboriginal & Torres StraitNot StatedCountry of Birth*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsHiddenDisability Type HiddenDisability or Condition*NoneIntellectual/LearningPsychiatricSensory/SpeechPhysical/DiverseHiddenExistance of Carer*NoYesHiddenWhy Come?Learn New SkillsImprove on Existing SkillsFix a ProblemNot SureHiddenAccomodation*Residential Aged Care or HospitalIndependant LivingBoarding HouseCrisis or EmergencyIndigenous Community/settlementPrivate Residence (Family Owned/Puchasing)Private Residence (Rental)HiddenLiving Arrangements*Not StatedSingle Living AloneCoupleGroup (Unrelated Adults)Group (Related Adults)Sole ParentCouple with DependantsHomelessHiddenDVA Card Status*No DVA EntitlementDVA Gold CardDVA White CardDVA Orange CardHiddenHow Did You Find Us?OtherWord of MouthHiddenHow Often Device Used?OccasionallyWeeklyDailyHiddenDigital Skills Rating?LowFairGoodExcellentHiddenConfidence LevelNot ConfidentA Little ConfidentSomewhat ConfidentConsiderably ConfidentVery ConfidentHiddenBe ConnectedNoYesHiddenPreferred DeliveryFace to FaceRemoteBothHiddenLearner Status Active Not Active (Withdrawn) Withdrawn (Do Not Contact) On Hold New Learner Form Completed Awaiting Tech Mate Unable to Contact HiddeniPad ProgramNo Devices LoanedClick and Connect (iPad Loaned)Making It ClickWSU Migrant Participation ProgramHiddenAgree To Be Contacted?NoYesHiddenSession Type*Face to FaceRemoteHiddenCHSPAreaWestern SydneyNepeanOrana Far WestCentral WestHiddenVenue*Please Select...Anglicare Retirement Village Castle HillBowen Mountain Community HallColo Heights HallHawkesbury Central LibraryLlandilo Community Hall, LlandiloPenrith Central LibraryRichmond Branch LibraryRiverstone Neighbourhood CentreRobin Wiles Park, North St Mary’sSouth Penrith Neighbourhood CentreSt Albans School of ArtsSt Mary’s LibraryThe Old School, LithgowThornton Community CentreWainwright Park, KingswoodWilberforce School of ArtsOtherHiddenMyAgedCare Access?NoYesWould the Learner like assistance with accessing the benefits in the MyAgedCare system?Consent* I agree to the privacy policy and have Learner consent in the Data Exchange.I agree to and have consent to collect the Learners personal information and store it on the Data Exchange and also to participate in any follow up research, along with these conditions in the Australian Government Data Exchange here.Session DetailsSession Date* DD slash MM slash YYYY Tech Mate Name*Please Select ...Neil DJung SRaymond TSajith BOtherMain Device Used*Please Select...iPhoneAndroid SmartphoneOther mobile phoneiPadOther TabletLaptop PCLaptop MacThey don't have a deviceOtherHiddenTech Mate Email Other Techmate Name First Last Please fill in your name here if it is not listed in the dropdown box.Length of Session* 30 minutes - 0.50 1 hour - 1.00 1.5 hours - 1.50 2 hours - 2.00 2.5 hours - 2.50 3 hours - 3.00 Mentor NotesComplete if you wold like to keep a record of progress.HiddenCategoryCommunicatingBasic InternetSocial MediaFiles and photos managementOnline Banking and shoppingGovernment services online (eg MyGov, E-Tax)Apps (e.g. Maps, iBook) or other Applications or GamesOnline Security (e.g. antivirus, scams)Other 34517
