This form is for new Community Hosts, or new Community Hosts who also wish to be Community Contacts. If you wish to become a Community Contact, without becoming a Community Host, please refer to the John Flynn Placement Program - New Community Contact Application Form. If you are an existing Community Host, or Community Contact, and you wish to update your details, please refer to the John Flynn Placement Program - Update of Community Contact and Community Host Details Form.

Community Host Personal Details

Title:

First Name:

Last Name:

Organisation (if applicable):

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 Host for your entire town?:

YES

NO (if no, please see next question)

Becoming a Community Host 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 Host:

Do you wish to become both the Community Host and the Community Contact for your chosen Town or Medical Practice/Organisation?:

YES

NO

Becoming both the Community Contact and Community Host for your town or Medical Practice/Organisation means that you will be entitled to receive both the Community Contact, and the Community Host payments.

Accommodation

Accommodation Details:

Please provide details of the accommodation you are able to provide the student.

Additional Information:

Please detail any additional information relating to the accommodation here.

Picking up the student on arrival: - None -YESNO

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

Local Transport:

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

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:

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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