Register – Clinical Student

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Your name
Name
First Last
Date of birth
MM slash DD slash YYYY
Gender
Are you of an Aboriginal or Torres Strait Islander background?
- Aboriginal
- Torres Strait Islander
- I do not identify as Aboriginal or Torres Strait Islander
- I would rather not say
2. Do you speak a language other than English (including AUSLAN or other sign language)? If yes, please list language/s spoken.
What, if any, specific cultural or ethnic group do you belong to?
Are you willing to be contacted regarding language and culture?
- Yes
- No
Your nearest Rocky Bay hub
Your email*
Your phone number
Current study course
Current year of study
Please enter a number from 1 to 10.
Current study institution
Any previous experience
Future career ambition/s
Special skills or interests
Emergency contact name
Emergency contact number
Emergency contact relationship
Any important medical information?
Any allergies?
How did you hear about Rocky Bay?
List two goals for your coming placement
File upload*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Please upload: - A valid Working with Children Check - A National Police Clearance from within the past 3 months - A Covid-19 vaccination certificate - An influenza vaccination from the past 12 months - A copy if your driver’s license
Name
First Last
Name
This field is for validation purposes and should be left unchanged.