Learner Enrolment Questionnaire | Revive Me CPR & First Aid Training

1 · DETAILS

2 · ADDRESS

3 · CONDUCT

4 · CONSENT

⚠️ Please complete all required fields before continuing.

Course Details

Course Number

Course Date(s) *

Please enter the course date.

Student Number

Type of Training *

Please select training type.

Programme / Unit Standard *

Please select a programme.

Personal Details

Title

Initials

First Name(s) *

Required.

Surname *

Required.

Date of Birth *

Required.

RSA ID Number *

Please enter a valid 13-digit ID number.

Alternate ID / Passport Number

Gender *

Female Male

Please select your gender.

Equity

Black-African Black-Coloured Black-Indian White

Highest Education

Current Occupation

Years in Occupation

Relevant Experience

Nationality

Citizen / Residence Status

Home Language

Socio-Economic Status

Disability Status

Geographical Area

Contact Details

Home Phone

Mobile Number *

Required.

Email Address *

Please enter a valid email address.

Preferred Communication

Email Phone SMS WhatsApp

Physical Address

Address Line 1 *

Required.

Address Line 2

City / Town *

Required.

Postal Code *

Required.

Urban / Rural

Urban Rural

Postal Address

Same as physical address

Address Line 1

Address Line 2

City / Town

Postal Code

Urban / Rural

Urban Rural

Employer Details (if applicable)

Employer Name

Direct Supervisor

Work Phone

Work Mobile

Work Email

Work Preferred Communication

Email Phone WhatsApp

Employer Physical Address

Address Line 2

City / Town

Postal Code

Learner Code of Conduct

As a learner enrolled with Revive Me CPR, First Aid and Safety Training, I agree to:

1. Attend all scheduled training sessions punctually and participate fully in all practical and theoretical components.

2. Treat the trainer, fellow learners and all training equipment with respect and care.

3. Conduct myself professionally and refrain from disruptive, dishonest or unsafe behaviour during training.

4. Complete all assessments honestly and without assistance, unless permitted.

5. Not attend training under the influence of alcohol or non-prescription drugs.

6. Follow all health, safety and hygiene instructions given by the trainer.

7. Bring a certified copy of my ID document on the day of training.

8. Understand that certificates are only issued on successful completion of all required assessments.

I have read, understood and agree to abide by the Learner Code of Conduct. *

You must agree to the Code of Conduct to continue.

POPIA Consent & Declaration

Protection of Personal Information (POPIA)

Revive Me CPR, First Aid and Safety Training collects the personal information in this questionnaire solely for the purposes of learner registration, training administration, assessment, certification and statutory reporting. Your information is stored securely, will not be sold or shared with third parties for marketing purposes, and is processed in accordance with the Protection of Personal Information Act, 4 of 2013. You may request access to, correction of, or deletion of your personal information at any time by contacting info@reviveme.co.za.

I consent to Revive Me processing my personal information as described above. * I declare that all information provided in this questionnaire is true, accurate and complete to the best of my knowledge. *

Both boxes must be ticked to submit.