Learner Registration Form

LEARNER REGISTRATION FORM

Please complete the following information and submit it to us. We will verify your information and payments. After that, we will send you the enrollment confirmation and login details to start the course.

Title *

First Name *

Surname *

ID Number **Please upload a certified copy of your ID at the end of this form*

Highest Qualification **Please upload a certified copy of your Highest Qualification at the end of this form*

Job Title

Cell phone number *

Email Address *All correspondence, course information and training will be sent to this email address

Home Street Address

Apartment, suite, etc

City

Province

Postal Code

Country

Postal Address optionUse same address as Street address

Postal Address

Next of kin information

Name and Surname* Next of kin *

Relationship* Next of kin *

Physical Address* Next of kin *

Contact Phone Number* Next of kin *

Gender

Equity Code

Citizen Status Code *

Immigration Status

Home Language

Nationality Code

Disability Code

Disability Rating

Social Economic Code

PAYMENT DETAILSRegistration fee R 500 (non-refundable)

PERSON / ORGANISATION RESPONSIBLE FOR PAYMENT

Email Address for invoice & statements

TERMS & CONDITIONS

Accurately complete this form in full.
Upload a copy of your ID, highest qualification and proof of payment.
If you do not receive a confirmation of registration within 24 hours, please get in touch with us on email: academy@healthileegroup.com
Banking details:

HealthiLee Care Academy (Pty) Ltd,
CAPITEC
Account: 2312 934 279

HealthiLee Care Academy reserves the right to refuse admission where proof of payment or a government order cannot be shown.
Cancellations/Postponements/Substitute learners must be done in writing (no later than 10 days before the course) to: academy@healthileegroup.com
A cancellation fee may be applicable for costs incurred.
In the case of cancellation or postponement of a course, HealthiLee Care Academy will not be liable for any incidental costs such as accommodation or travel costs that were incurred by a client in relation to the intended course.
HealthiLee Care Academy reserves the right to change the presentation, content or facilitator for a course.

Upload copy of your IDfile types accepted: .pdf .jpg .png .gif .jpeg

No file chosen

Upload proof of paymentfile types accepted: .pdf .jpg .png .gif .jpeg

No file chosen

*Please bring all the original documents to class on your first day of training.

LEARNER REGISTRATION FORM

Next of kin information

If You Have Any Question, Feel Free to Call Us

If You Have Any Question,
Feel Free to Call Us