Rural Clinical Elective Application Form

Announcement

International electives are currently suspended. WA and Interstate students may now apply again.

Submission Time Frames

Important Notice for Elective Placement Period

Period	Submission Commencement	Submission Deadline	Review Period
December 2021 / January 2022	04-May-21	30-Jun-21	July 2021

Please note that we will not assess applications received outside of the above timeframes.

Personal Details

Family Name:

Title:

Given Name:

Preferred Name:

Correspondence Address:

Home Address (if different from Correspondence Address):

Country:

Telephone: Please ensure you prefix the number with your country code.

Email Address:

Nationality:

Passport Number:

Date of Birth:

Gender:

Emergency Contact Name:

Emergency Contact Telephone:

Emergency Contact Address:

Emergency Contact Relationship:

Have you received notification of a confirmed two week RFDS placement?

Please list your three preferred location/hospital in order (the maximum period is four weeks). Please note placements are ONLY during the periods July/August OR December/January. Placement requests outside these periods WILL NOT be considered.

Total number of elective weeks (the maximum period is four weeks):

Please state in 500 words or less why you have chosen particular rural sites for your elective.

Please specify your three preferred elective dates:

Elective from:

To:

Elective from:

To:

Elective from:

To:

Have you contacted any department/s, if so, who/where?

Academic

Current University/Medical School Name:

Course Contact Name:

Course Contact Email:

Present Year of Study:

Year of Graduation:

Month of Graduation:

Fees

Students who are offered a placement will be charged a non-refundable placement fee which is paid online once details are confirmed:

International medical students: $1,000.00
Australian and NZ medical students: $220.00
UWA & Notre Dame Fremantle medical students: No fee

Student’s Knowledge of English

Documents

Documents required to be uploaded when submitting this Application:

A copy of the identification pages of your passport endorsed by your Faculty representative (not applicable for UWA or Notre Dame Fremantle medical students);
Proof of proficiency in written and spoken English — if not your first language, or your course is not taught in English, IELTS or TOEFL or a statement from your university. You must be able to understand, write and speak English competently;
A letter from your Faculty confirming your student status and level and in good standing;
Your current CV;
Any additional documentation you deem appropriate to submit.

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Submission

By submitting this form, you:

agree that the specified fees are non-refundable; and
have supplied the correct information in the form; and
attached the required identity and eligibility documentation.

I agree with the specified terms of submission.