Dermatological Surgery Workshop - RWAV Scholarship Application Form

Last updated 16 January 2024

For more information on this scholarship opportunity, the requirements of the workshop and the Terms and Conditions, you can view the Dermatological Surgery Workshop Scholarship page.

* denotes required field

First name:

Last name:

RACGP ID:

Email:

Mobile number:

Clinic name:

Clinic address:

Clinic suburb:

Modified Monash Model (MMM) area:

Find the MMM area here

Are you employed a minimum 8 hours per week in the private practice or non-state government primary health sector?:

YesNo

Preferred workshop:

Please select one

Dietary Requirements:

I agree with the terms & conditions:

I agree with the terms & conditions as outlined above

I will be able to complete the pre-requisite :

I will be able to complete the pre-requisite DermCert 4: Practical procedures in dermatology course online prior to the workshop.

I agree for the RACGP to share my details:

I agree for Royal Australian College of General Practitioners (RACGP) to share my professional details with the Rural Workforce Agency of Victoria (RWAV)

Declaration:

I declare that this application form has been completed independently by me and the information provided is accurate at the time submission.

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