Update of Student Details Form

Last updated: 17 June 2011

This form is for current John Flynn Students only. Please fill in all applicable fields.

Contact Details

Title:

First Name:

Middle Name:

Last Name:

Street Address:

Postal Address:

Suburb:

State:

Post Code:

Phone Number:

Mobile Number:

E-mail Address:

Out of Semester Phone Number:

Out of Semester E-mail Address:

Emergency Contact Details

It is mandatory that you provide the JFPP with an emergency contact.

Contact Name:

Relationship to you:

Street Address:

Phone Number:

Mobile Number:

University Details

University Name:

University ID Number:

Graduate or Undergraduate?:

Name of Course:

E.g. MBBS

Enrolment Year:

Graduating Year:

Are you a member of any of the following:

Rural Health Club

AMSA

GPSN

If yes, please provide details:

Personal Details

Date of Birth:

Gender:

Allergies/Medical Conditions:

Please detail any Allergies or Medical Conditions you may have.

Do you identify with any of the following groups?:

You are not required to disclose your cultural identity.

Rural Origin

Are you of Rural or Remote Origin?:

YES

'Rural or Remote' is any location in RA's 2 - 5. If you would like to check which RA your town is in, you can do this at http://www.health.gov.au.

Name of Town:

State:

Number of Years Spent in a Rural Town:

Additional Information:

Please detail any additional information you feel may be relevant.

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Update of Student Details Form