Course Application Form

Contact Details

Surname:
Other Names in Full:
Preferred Name During Course:	if different to above (ie. for name tag):
Postal Address:

City/Town:
State:
Postcode:

Business Number:
Fax Number:
Private Number:
Mobile Number:

Email Address:
(Applications are acknowledged by email where provided.)

I am prepared to travel interstate for the course.
Yes	No

Have you previously attended an ELS Course?
Yes	No

Education

Year of Graduation:
University:
Qualifications:
Postgraduate Emergency care Training or Experience:
(eg. in Emergency Departments, Anaesthetics or ICU )

Current Position

(Please Tick)
	RMO
	CMO / HMO
	GP Registrar (Rural Pathway)
	Registrar
	Rural General Practice
	Metropolitan General Practice
	Other (please specify below)
Other:

If you are a Registrar, please state type and level of training.


What are your reasons for applying to do the ELS course?


Are you applying to attend an ELS Course to fulfil reqirements for the ACEM Emergency Medicine Certificate?
Yes	No

What is the nature of your current involvement in the care of seriously ill patients?

Course Fee:

The ELS course is a non-profit organisation and your course instructors are donating their time and expertise free-of-charge.

The break-even cost to run the ELS Course is $(AUS)1720 (GST inclusive) per participant. This amount is due for payment ten (10) weeks prior to the course. The ELS Course Committee of Management reserves the right to adjust course fees if the need arises.

Once the course fee has been received, the course manual and pre-course package will be posted approximately six (6) weeks prior to the course.

Refund Policy:

1.	No refund will be given if a course enrolment is cancelled within 7 weeks of the course date.
2.	No refund will be given for non-attendance at a course.
3.	A refund (less applicable fees) will be issued if a course enrolment is cancelled more than 7 weeks prior to the course date.
4.	Cancellation of a course enrolment must be submitted in writing to the ELS Course Office at least 7 weeks pior to the date of the course.
5.	Fees: - Administrative fee applied to all refunds - $150 - Fee applied if the course manual has already been posted - $220 (in addition to administrative fee above)

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