Student Application - Penultimate Year • RCSWA Forms

Important Notice

This form must be returned NO LATER than 7th of May, 2025 11:59PM.
Late applications will not be accepted.

IMPORTANT
Your home university will be provided with a list of applicants and will be asked to endorse applications based on academic standing and professional behaviour.
Non-endorsed applications will not proceed.

Student & Personal Details

Student Details

* Student Number:

* University:

Personal Details

* First Name:

Middle Name:

* Family Name:

* Preferred Name:

* Title:

* Home/Postal Address:

* Town/Suburb:

* State:

* 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.

* Date of Birth:

* Gender:

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?

If yes, please provide more information so we can best assist you:

Driving

* Do you have a current WA Driver's Licence?

* Are you a probationary driver?

If yes, what date did you obtain your Driver's Licence?

Photograph

Please attach a head and shoulders photo of yourself - please go to: https://youtu.be/TwwZdo_1BZU for instructions on how to properly take a photo. Photos will be sent away to be standardised. Please ensure you are not wearing a hat or sunglasses and do watch the YouTube video on proper technique.

RCSWA Placement Details

Site and Latitude Preferences

* Please specify whether you would like to be placed at a small or large site:

* Please specify whether you would like to be placed in a north or south site:

If you would like to be placed at a specific site/s, please specify the site/s and describe in 25 words or less your reason for requesting it: NOTE: Although we cannot guarantee placement in a particular site, please let us know if you have a reason you are seeking a specific site.

Small/Large Site Preference

* Why have you applied for either a large or small site? (can select more than one option) Better chance of getting in Limited knowledge of the differences No preference for a large or small site Other (please specify)

* If you have ticked other, please provide more information:

Small Site Preference

* Why have you applied for a small site? (can select more than one option) Better chance of getting in Closer interaction with clinical staff will improve my skills Considering a career in General Practice in smaller rural areas Other (please specify)

If you have ticked other, please provide more information:

Large Site Preference

* Why have you applied for a large site? (can select more than one option) Bigger hospitals to get clinical experience Partner or family reasons Work better in larger groups Other (please specify)

* If you have ticked other, please provide more information:

Additional Preferences

I would like to go to the RCSWA with (please name one or two colleagues):

* Please select whether you prefer LOCATION, COLLEAGUE or DOESN'T MATTER:

Site Preference Survey

* Do you feel you had sufficient information to make a choice about your preferred RCSWA location in 2026?

* If yes, what information was useful; if no, what information would have been useful?

Questionnaire

Pathways & Bonded Scholar

* Please indicate what entry pathway you entered the medical course via? If your pathway is not listed, please specify it below:

* Are you a bonded scholar?

Rurality Information

Please provide details of your most recent five years of rural residence (MMM 2-7). This information is used in our selection scoring process.
We are asking about your most recent years living in rural areas (MMM 2-7), even if these were before you started medical school
Must be your principal residence (not holiday homes or temporary addresses)
If you lived in the same rural place for multiple years, enter it for each year
If you have never lived rurally, please enter your current address for all five years
Use the MMM 2019 classification from: http://doctorconnect.gov.au/internet/otd/publishing.nsf/Content/locator
Example 1 (Rural background): If you lived in Broome from 2015-2019 before moving to Perth for medical school, enter your Broome details for all five years
Example 2 (Metropolitan background): If you have always lived in metropolitan areas (MMM 1), enter your current address for all five years

Note: The Modified Monash Model (MM) classification helps us understand your level of rural exposure.
MM1 is metropolitan, while MM2-7 represent increasing degrees of rurality.

Town/Suburb	Year	Post Code	MM #

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?

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.

Interviews & Submission

Interviews

Interviews will be held in Microsoft Teams. All applicants will be offered an interview.
An appointment will be allocated to you on 18 or 19 June 2025. If there are any times you unavailable over those two days please note it below.

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