Course Application Form

Contact Details

Surname:
Other Names in Full:
Postal Address:

City/Town:
State:
Postcode:

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

Email Address:

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?

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)1498 (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 of Course Fee:

All requests for a refund of the course fee must be submitted in writing to the ELS Course Office.

1.	A full refund will be given provided written notice is received at least seven (7) weeks prior to the Friday preceding the course.
2.	No other refunds will be given unless a doctor already on the ELS Course Waiting List is prepared to take your place in the course.

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