RCSWA Forms
Student Application - Final Year
Important Notice
This form must be returned NO LATER than 5pm on Friday 2nd August, 2024.
Late applications will not be accepted.
Student & Personal Details
Student Details
*
Student Number:
*
University:
-- PLEASE SELECT --
UWA
UNDA - Fremantle Campus
UNDA - Broome Campus
Curtin
Personal Details
*
Given Name:
Middle Name:
*
Family Name:
*
Preferred Name:
*
Title:
-- PLEASE SELECT --
Mr.
Ms.
Mx.
Mrs.
Miss.
*
Home/Postal Address:
*
Town/Suburb:
*
State:
-- PLEASE SELECT --
Australian Capital Territory
New South Whales
Northern Territory
Queensland
South Australia
Victoria
Western Australia
*
Post Code:
*
Mobile Phone:
Please enter phone number ONLY with no spaces - numbers only (e.g. 0898420891)
*
University E-Mail Address:
The address MUST be an university email, and therefore end in
.uwa.edu.au
.
*
RCSWA E-Mail Address:
The address MUST be your RCSWA email, and therefore end in
.rcswa.edu.au
.
*
Date of Birth:
*
Gender:
-- PLEASE SELECT --
Female
Male
Other / Non-Binary
*
To ensure we address you appropriately in our communications, please indicate your preferred pronouns:
-- PLEASE SELECT --
He/Him/His
She/Her/Hers
They/Them/Theirs
Other (please specify)
Prefer not to say
Note: This information will be used by RCSWA staff to ensure respectful communication. You may update this information at any time by contacting your site's ASO.
Other pronouns:
*
Do you identify as Aboriginal and/or Torres Strait Islander?
-- PLEASE SELECT --
No
Yes
Emergency Contact
*
Emergency Contact Name:
*
Emergency Contact Telephone:
*
Emergency Contact Address:
*
Emergency Contact Relationship:
*
Do you have any disabilities, chronic illnesses or other issues which we should know about in order to assist you while on placement?
-- PLEASE SELECT --
No
Yes
If yes, please provide more information so we can best assist you:
RCSWA Placement Details
Site Preferences
*
Please rank your preferred sites. If you have one preferred site, please do not select any others.
Rank #1:
-- PLEASE SELECT --
Albany
Broome
Bunbury
Geraldton
Metro
No site preference for this rank
Rank #2:
-- PLEASE SELECT --
Albany
Broome
Bunbury
Geraldton
Metro
No site preference for this rank
Rank #3:
-- PLEASE SELECT --
Albany
Broome
Bunbury
Geraldton
Metro
No site preference for this rank
Rank #4:
-- PLEASE SELECT --
Albany
Broome
Bunbury
Geraldton
Metro
No site preference for this rank
Questionnaire
Bonded Scholar
*
Are you a bonded scholar?
-- PLEASE SELECT --
No
Yes
Further Information
Answers to the following questions will have no impact at all on your final year placement. This information will only be needed in the event that you are successful in your application and will help the administrative staff in preparing for your relocation and arrival at your RCSWA site.
Accompanying Family
*
Do you have family who will spend the academic year in the Rural Clinical School with you?
-- PLEASE SELECT --
Yes
No
If YES, please provide details below...
Partner's Name:
Partner's Occupation:
Names and ages of children:
Do you have any special dietary requirements?
Please list any hobbies or sporting interests you have.
Staff at all sites may be able to assist you in finding part-time employment. Please list any employment options you would like the RCSWA staff to explore if you are successful in your application.
Final Year Information
Accommodation
*
What are your proposed accommodation arrangements for your preferred location/s in 2026?
-- PLEASE SELECT --
Staying with friends / family
Already have accommodation
Other / Specify in Comments
Seeking RCSWA provided accommodation at $230/week
Intend to seek a rental property
Unknown
Additional information/comments:
Statements
*
Q1: Describe any experiences you have had in a regional, rural or remote community. This can include employment, cultural ties, living arrangements, study etc. How has this contributed to your understanding of rural and remote medicine?
Maximum 200 words, please be succinct
*
Q2: Reflecting on your time in the RCSWA Penultimate Year program (with both RCSWA staff and non-RCSWA clinical staff), provide an example of your ability to communicate well with others and your approach to working with others. Describe any areas of your communication skills you wish to develop.
Maximum 200 words, please be succinct
Students completing the RCSWA Final Year program must complete their home university curriculum and self-direct their learning to ensure home university compliance and completion of their studies. This is different to the Penultimate Year program, which offers one curriculum that all students at all sites complete.
*
Q3: Describe how your approach to self-directed learning will support your completion of the academic year.
Maximum 200 words, please be succinct
*
Q4: Describe why you believe completing the RCSWA Final Year program will enhance your rural medical career.
Maximum 200 words, please be succinct
Referees
Provide a referee of your choosing - someone who has supervised you in the clinical environment this year.
*
Full Name:
*
Mobile Number:
*
E-Mail Address:
*
Occupation:
*
How do you know this person?
Financial Independence
*
Please attach a Statutory Declaration of financial independence.
You can submit your Statutory Declaration AFTER the application deadline if necessary by contacting Ashleigh Fielding via email.
(
ashleigh.fielding@rcswa.edu.au
)
Submission
Submission
By submitting this form, I declare that the above information provided by me in connection with this application is true and correct.
I agree to the use of my basic contact information to follow my career journey and to inform me of future rural health opportunities.
Name:
University E-Mail:
Mobile:
Personal E-Mail:
Please enter your e-mail address to receive a confirmation of the submission:
The e-mail address must end in
edu.au
