Mannum Clinical Skills Registration

First Name
Surname
Known As
Gender	Male Female
Student ID
Postal Address
Suburb
Post Code
Contact Number
Email Address
University
Current Year Level
Please indicate which RDWA sponsored clinical skills trips you have been on? (eg Pt Augusta/Quorn, Mt Gambier, Riverland
Are you an International Student?	Yes No
Please specify any specific dietary requirements (eg vegetarian, vegan, allergies, Halal)
I consent for Rural Doctors Workforce Agency to use or reproduce any photographic images taken as part of educational activities &/or events in publications or other media material produced, used or contracted by the Rural Doctors Workforce Agency including but not limited to: newsletters, flyers, brochures, newspapers, magazines and websites, online groups and forums.	Yes No