RURAL CLINICAL PLACEMENT GRANTS 2017

Application Form

Applications open 14th November 2017 at 9am and close 24th November 2017 at 5pm EST.

Please ensure that you have read the RWAV Rural Clinical Placement Grants 2017 Guidelinesprior to completing your application.

Complete this application form and return it along with the letter of confirmation (details in guidelines) to:

Email

1.Personal details

First name: / Surname:
Postal address: / Town:
Postcode: / Phone:
Email:

2.Course details

University: / Campus:
Course: / Year of course:

3.2017 Undergraduate Scholarship recipient

Have you received an undergraduate scholarship or grant from another organisation for 2017 relating to this clinical placement?

Yes / No

4.Rural Background Details (if applicable)

To meet the regional and rural residency criteria: Applicants must have lived for at least 5 years consecutively or 10 years cumulatively after birth in a place classified by the Australian Geographic Classification- Modified Monash Model system as level MM 2-7 .

Do you have a rural background? / Yes No
Residential Address:
Town: / Postcode:
State : / Duration of residence:

5.Clinical placement details

Organisation name:
Address:
Town: / Postcode:
Dates of placement: / Duration of placement:
Has this placement been organised? / Yes / No / Still in process

6.Travel details

Travel includes: Return transport from your permanent place of residence to clinical placement location at the commencement and conclusion of the placement.

I am claiming for travel Yes No

Public transport / Yes / No / Cost:
Driving / Yes / No / Total Kms: (66cents per km as per ATO)

Please provide tax receipts and/or vehicle logbook (see guidelines)

7.Accommodation details

I am claiming for accommodation Yes No

Accommodation name:
Address:
Town: / Postcode:
Cost per night: / Total cost:
Has accommodation been organized? / Yes / No / Still in process

Please provide tax receipts for all accommodation claims

8.Additional information

8.1 What do you hope to/ did you learn from your rural clinical placement? (max. 250 words)

8.2 How did your clinical placement benefit the community you were placed in? (max. 250 words)

8.3Provide your rural clinical placement history

8.4What was the total cost of this clinical placement?

8.5 For RWAV future planning, are there any other costs associated with this placement that you would benefit from having financial assistance with?

9.Agreement

Name of applicant:
Date:

In submitting this application form, I agree that I understand and will follow the conditions of the grants as outlined in this document and the RWAV Rural Clinical Placement Grants 2017 Guidelinesif I am successful in obtaining a grant.

I acknowledge that information collected in this application may be used in accordance with RWAV’s Privacy Policy and consent to it being used or disclosed for the purposes described in the Privacy Policy

NOTE: If you are successful in receiving a grant, payment will only be made upon RWAV receiving evidence of receipts for accommodation and travel and travel log.

Sign here

Thankyou for your application.

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