#LoveAndSupport®

Applicant’s Name: _________________________________________________________________________

Date: _________________________________________________________________________________________
How did you know about us? ______________________________________________________________
OFFICE USE (HELP DESK CONSULTANT)
Name:
_________________________________________________________________________________________________
REGISTRATION AND ACCREDITATION
Mpilo Royal College is accredited by Quality Council (QCTO) Accreditation
Number – QCTOSDP01200312-1964. HWSETA Accreditation Number –
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
Page | 1
(NB): No late applications will be accepted and all registration fees are non refundable

PHASE TWO

Registration requirement: Registrations requirements depend on the requirements specified

for each learning programme. A minimum Admission requirements is Matric with 33.3% in
Maths and English or grade 10, 11 or 12 plus FLC or ABET Level 4 plus FLC.

PLEASE ATTACH 2 CERTIFIED COPIES OF ID, 2 LATEST ACADEMIC, TERTIARY

EDUCATIONAL CERTIFICATES AND CV.
International Students

1) International student who reside in South Africa must

i) have student permit, workers permit or valid asylum
2) International student applying from their countries of origin must have
i) 2 (two) certified copies of the valid passport
ii) Pay stated full registration and deposit
3) All international student must have
i) High school certificate valuated by SAQA (South African Qualification Authority)
www.saqa.org.za, Tel +2712431500
ii) High school certificate equivalent to Matric with 33.3% in Maths and English or grade
10, 11 or 12 plus FLC.

NB: We assist international student with Study permit application. Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
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LEARNER INFORMATION
Name of the College:_______________________________________________________________________________________

Name of the Course:_______________________________________________________________________________________

Course start date: _________________________________________________________________________________________

Sponsor Name: ____________________________________________________________________________________________

Venue: JHB CAMPUS

LEARNER DETAILS:

TITTLE: MR/MRS/MS _______________________________________________________________________________

Name and surname: _____________________________________________________________________________________

ID No: ___________________________ _________________________________________________________

Page | 2
CONTACT DETAILS:

Home Address:1 ________________________________ Home Address 2:___________________________________

________________________________ ________________________________________

________________________________ ________________________________________

Province ________________________________ Town: ______________________________________

Postal code: __________________ Postal code: _________________________

Postal Address: _________________________ ____________________________________________________

_______________________________________ ______________________________________

Postal code: __________________

Telephone no: Home: ( ) ______________________________ Cell: ( ) _______________________

Fax: ( ) ______________________________ Cell: ( ) _______________________

E-mail: _______________________________________ ______/___________________________________________________ Initials

Facebook Profile Name:

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

http://www.facebook.com/ _____________________________________________________________________________

Whatsapp Number: _______________________________________________________________________________________

DEMOGRAPHIC INFORMATION:

Age: _____________________ Gender: ____________________________ Occupation: _____________________________

Employed: _________ Unemployed: __________ Citizenship: _________________________________________

Disability Status:__________________________________________

City/Town:_________________________________________________________________________________________________

Municipality:_______________________________________________________________________________________________

Province:__________________________________________________Rural/Urban__________________________________

STATSSA AREA CODE: ____________________________________________________________________________________

Page | 3
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: ( ) __________________________ Initials

E-mail: __________________________________________________________________________________

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

Facebook Account: _______________________________________________________________________________________

WhatsApp number: _______________________________________________________________________________________

Write the programme name for which you

would like to register, e.g. Health Promotion
Officer (HPO) see academic programme
brochure for more details)

LEARNER EDUCATION AND TRAINING BACKGROUND:

Highest qualification Obtained (grade 10, 11, 12 etc.):

Page | 4

Highest SAQA Equivalent qualification to (grade 10, 11, and 12 etc.):

Prior/previous learning experiences/skills (with regard to this learning programme):

______________________________________________________________________________________________________________

Language preference:
______________________________________________________________________________________________________________

Initials

LANGUAGE SKILLS:

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
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English Excellent Average Poor

Read
Writing
Speaking

HOME LANGUAGE:

1.................................... Excellent Average Poor

Read
Writing
Speaking

SPECIAL LEARNING NEEDS (State relevant disabilities or learning difficulties)

Page | 5
SPECIFIC LEARNING NEEDS (with regards to the above mentioned disability or learning
difficulties if there is any):

ANY CHRONIC CONDITION/DISEASE (If available please bring medical report)

_____________________________________________________________________________________________________

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

MOTIVATION FOR ENROLLING FOR THIS COURSE:

______________________________________________________________________________________________________________

Page | 6

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

LEARNER’S CONTRACT
Full names and surname of a learner __________________________________________________ ID:_______________

Declare, agree and undertake the following towards the MRCHE:

1) That I shall acquaint myself with the content of rules and regulations of MRCHE that apply to me
in general as well as to the course for which I am registering and that, for the entire duration of
my study, I commit myself to fulfill these rules and regulations as well as to the additional rules
and regulations that MRCHE may announce thereof.
2) That failure to fulfill these rules and regulations can lead to disciplinary steps being taken,
including permanent suspension from the college
3) 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 my study or research project that I undertake or may undertake
at MRCHE or that I develop with the assistance of the MRCHE equipment except where otherwise
agreed;
4) 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.
5) That I undertake to sign any document, whenever necessary, to cede and transfer the rights
concerned;
6) 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;
7) That MRCHE is entitled to summarily cancel my registration at any time if false/incorrect
information is provided to MRCHE
8) That I indemnify MRCHE against any liability damage of whatsoever nature that I may cause
Page | 7
while I am registered as a learner at the college, irrespective of whether liability or damage that
result from any of my activities in the premises of the college
9) I must complete the official registration form and submit specified registration requirements in
each course that I am registering for.
10) That I shall acquaint myself with the admission requirements of MRCHE for the course which I
am registering and shall fulfill these requirement at the commencement of academic year;
11) No registration will take place unless a minimum amount of fee as stated in the course brochure,
has been paid;
12) All registrations fees are non refundable
13) Registration period will depend on the notional hours specified for each course
14) I am aware that I will attend classes after a specified deposit is paid
15) No refund will be considered after 5 days of attending classes should I cancel my course or fail to
attend my course.
16) I must pay all costs including bank charges, late assignment submission fee, fee for extension of
training as determined by the college, late payment fee 2% of the amount due on that period and
reasonable administrative fees payable by us for making use of such services.
17) Course fees are payable on EFT only and on monthly installment basis
18) If am paying on an installment basis my monthly installment must be paid on or before the (1)
first day of each month.
19) All outstanding fees must be paid in full before the course ends, failure to do so will result in the
decision to delay the student from writing national exams until the fees are settled.
20) For any outstanding fees not paid the college shall take up the matter with the legal department
in the form of attorneys or debt collectors to recover the money.
21) Uniforms and portable equipment are available on campus and they are not included in the
school fee but are available for sale.
22) Learning Materials are provided in a free tablet in the form of eBooks
23) Transport to clinical/ practical, Indemnity Cover, Accommodation, Student Name Tags, Access
Cards and portable nursing equipment is my own responsibility
Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

24) 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.
25) Phone calls- a single phone call of collection / reminder for you to pay schools fees that are due,
will costs R20, whether our agents/officers reached you/guardian or not. This amount will be
included on a monthly invoice if you were called with regards to fees payment due.
26) The college reserves the right to increase fees if necessary.
27) It is my responsibility to buy /supply additional materials deemed necessary for my studies.
28) I understand that by scheduling myself for internal and external exams on the agreed date, I
commit to avail myself.
29) A separate form for national examination enrolment shall be completed and the prescribed fees
be paid at the end of the course.
30) I understand that if I fail to submit my portfolio as per agreed date it will cost me R2000 penalty
fee.
31) Am aware that I will not be allowed on campus if my account is in arrears.
32) The right to attend lectures and write exams is not transferable. Accordingly, I shall attend all
lectures in person and shall be the only person entitled to write examinations in respect of the
subjects forming part of Mpilo Royal College course which I have enrolled for. Under no
circumstances will NOT be permitted to write exams if any amount is outstanding and the full
fees and other amounts due under this contract are not paid in full prior to such exam.
33) In the case of an extraordinary event or circumstance beyond the control of such parties, such
as war, strike, riot, crime, act of God (e.g. earthquake, volcano), Mpilo Royal College will be
entitled to suspend lectures and temporarily close any campuses affected thereby. I (where the Page | 8
consumer is not also the student) shall not by reason of such suspension or closure be entitled
to terminate this agreement or claim a refund, fees paid or a reduction on fees payable or any
compensation from Mpilo Royal College.
34) I accepts, as stipulated in Mpilo Royal College examination/assessment Policy (which shall be
deemed to form part of this agreement) that as part of the examination of the course, I must
fulfil certain academic requirements, which may include (but are not limited to) the completion
and/or sign-off of a Portfolio of Evidence, required number of workplace learning hours or
practical hours or other forms of assessments. I understands that submission of any academic
work should be my intellectual work. Should submission of any academic work not mine, it will
constitute fraud, which may result in my expulsion from the college.
35) I understand that by failing to comply with this agreement will result in an immediate
termination and l will be fully liable for all outstanding fees.

………………………………….
LEARNERS SIGNATURE

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

Protection of Personal Information

The Parties acknowledge their respective obligations to comply with the substantive
provisions of the Protection of Personal Information Act, 4 of 2013 (hereinafter referred to as
‘POPI’). The personal information received shall not be further processed or disclosed without
the consent of the disclosing party. The student/consumer hereby authorises Mpilo Royal
College or any other authorised member of the management team to use, review and process
any personal information provided to Mpilo Royal College and to use same in the manner that
Mpilo Royal College sees fit. The persons signing this agreement acknowledge that they know
and understand their right to privacy and to have their personal information processed in
accordance with the conditions for the lawful processing of their personal information, and
hereby give their consent to Mpilo Royal College to collect, process and distribute relevant
personal information where Mpilo Royal College is legally required, and/or obliged to do so.
They also consent to any third party service providers to have access to their personal
information and consent to Mpilo Royal College sharing same. The persons signing this
agreement confirm and acknowledge that they are aware that the information that they have
provided may be transmitted to persons, companies, subsidiaries, affiliates and third parties in
the Republic of South Africa and hereby consent in terms of section 72 of POPI to such
transmission and use by Mpilo Royal College of Health Education.

POPI ACT AGREE

YES: Page | 9

NO:

DATE: ______________________ Sign: ___________________________________________

Legal Declaration and Indemnity

Neither Mpilo Royal College nor any official employee or representative of Mpilo Royal College
acting in his/her capacity as such shall be liable for any damages arising out of: the death,
bodily harm, loss of health or illness of any customer caused; and the destruction of and/or
damage and/or loss and/or theft of any property owned by or in the custody of any customer,
howsoever caused. The student/consumer hereby indemnifies Mpilo Royal College against any
claim made (whether for damages, costs, or otherwise) against Mpilo Royal College in respect
of any action and/or omission of the student and/or the consumer (where the consumer is not
also the student). The student by his/her signature hereby confirms that he/she is fully aware
of the type of course and/or programme enrolled for and that it is his/her responsibility to
make himself/herself aware of the types of courses and that he/she has fully understood the
course that he/she registers for and is indeed the course that he/she wants to register for and
that no representations have been made other than those contained in the official brochure.
The student/consumer hereby indemnifies Mpilo Royal College (Pty) Ltd against any claim
they may have. The student is further aware of the factsheet in respect of the
programme/course enrolled and confirms that it accurately reflects the qualification to be
conferred and the type of programme/course registered for.
Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

Rules and Regulations

The student/consumer by his/her signature hereto hereby acknowledges that he/she has
read and agrees to abide by all the rules and regulations of Mpilo Royal College that
he/she attends and acknowledges that he/she can be disciplined in terms thereof. The
student/consumer further acknowledges that right of admission to Mpilo Royal College
campus is strictly reserved and Mpilo Royal College may, at its own discretion refuse
admittance to any student and/or consumer.

…………………………………..
LEARNERS SIGNATURE

PARTICULARS OF PAYMENT
Indicate the payment option below with your “signature” as well as the payment amount.
Deposit into MPILO ROYAL™ COLLEGE OF HEALTH EDUCATION, (NEDBANK BALFOUR
PARK, ACCOUNT NUMBER: 1022300326, BRANCH CODE: 151105

Reference: Student Name And Surname) may only be made if a copy of deposit slip is
attached to the registration form.
Page | 10

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:...................................................

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

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 ROYAL™ 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……………………………….. Page | 11

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za
#LoveAndSupport®

CANCELLATION POLICY ACKNOWLDGEMENT

DECLARATION AND UNDERTAKING
I ___________________________________________________________________________________________________________
fully undertake responsibility and declare that:

(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 that I
paid for.
Page | 12
(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 Mpilo Royal™ College and proper measures will be followed.

Date………………………………….
Learner’s signature………………………………..

Initials

Tel: 0861 091 092 | Fax: 086 621 7583 | Cell: (078) 526 1127
21 Kruis Street, 2nd Floor, Marshalltown
Johannesburg 2001
Email: [email protected] | Web: www.mrche.co.za