Please fill in this form if you wish to become a Community Contact. If you wish to become a Community Contact and a Community Host, please refer to the Community Host application form. If you are already a JFPP Community Contact, and you are wishing to update your details, please refer to the John Flynn Placement Program - Update of Community Contact and Community Host Details Form.

Community Contact Personal Details

Title:

First Name:

Last Name:

Organisation:

Position:

E-mail Address:

Telephone Number:

Mobile Number:

Street Address:

Postal Address:

Town:

State: - None -ACTNSWNTQLDSATASVICWA

Post Code:

Do you wish to become the Community Contact for your entire town?:

YES

NO (If no, please see next question)

Becomming a Community Contact for an entire town means that you are willing to accept students from any Medical Practice or Hospital in your town.

Please give the Name of the Medical Practice/Organisation for whom you wish to act as Community Contact:

ABN

Please provide your ABN if you have one. If you do not have an ABN, we will require you to fill in a statement by supplier form, for our records only. We will forward this form to you at a later date.

Do you have an ABN?:

YES (Please enter below)

NO

ABN :

Referee

Please nominate a character referee.

First Name:

Last Name:

Organisation (if applicable):

Position (if applicable):

E-mail Address:

Telephone Number:

Community Profile

Support and Integration:

Briefly outline how you, or your Organisation will introduce and support JFPP medical students to integrate into the life of your community.

Activities:

List some of the activities which may be available to students (generally aged 20 - 30 years), bearing in mind that they will visit for only 2 weeks per year. Such activities could be social, sporting or cultural.

Local Area Website:

Please provide a local area website address if you know of one.

Accommodation

JFPP Student accommodation is organised and paid for by the program. Depending on availability, students may stay in community hosted or hospital/nurses accommodation. Please provide names/details of any person or organisation that may be able to assist with this accommodation.

Please contact me to receive accommodation details:

YES

NO

First Name:

Last Name:

Organisation (if applicable):

Telephone Number:

E-mail:

Type of accommodation:

Local Transport:

Please provide relevant details of local transport options (eg: taxi number, availability of buses, local car hire, etc.)

Picking the student up on arrival:

YES

NO

Can you, or someone from your Organisation meet students at the local airport, bus or train station and provide transport to their accommodation?

Mentor

The JFPP students complete one 2 week placement each year over 4 years, with the same Mentor or Medical Practice.

Can you suggest a Mentor or Medical Practice in your town?:

Yes

No

Please contact me to receive contact details of a potential Mentor:

YES

Practice Name:

Telephone Number:

Mentor Name:

Mentor Telephone Number:

Mentor/Practice E-mail:

Additional Information:

Please detail any additional information you feel may be relevant.

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