CPMS - Admin :: Student Registration : Add new

UCRH Student Placement Application

Thank you for your interest in a placement with the University Centre for Rural Health.

Please note our registration process has been two steps.

STEP 1: complete this registration form, and

STEP 2: If your placement is accepted, you will receive an email to log into our student portal to complete the second step of this process. Please note if you do not complete the second step, you WILL NOT be allocated accommodation.

You will be able to save you application and return to complete it if necessary.

If at any point you wish to exit the application process, please ensure you save the authomatically generated return code so you can return and complete you application.

Thank you!

What UCRH campus will you access?

* must provide value

(Please note students assigned to maclean schools/aged care placement are to select Lismore. Students who have a placement in Ballina should also select Lismore Campus.)

Last Name

* must provide value

First Name

* must provide value

Middle Name

* must provide value

Date of Birth

* must provide value

Title

* must provide value

Gender

* must provide value

Citizenship Status

* must provide value

University

* must provide value

University ID

* must provide value

(Student ID Number)

Course Name

* must provide value

Year Level

What year of your degree are you currently enrolled in?

My study level is

Student Email

* must provide value

Personal/Secondary Email

(by providing your personal or secondary email address you are opting into having your details stored in the UCRH Alumni database where you will be notified about upcoming event, training, job etc)

Home Phone

* must provide value

Mobile

* must provide value

Home Address 1

* must provide value

Home Address 2

Home Address City

* must provide value

Country

* must provide value

Home Address State

* must provide value

Home Address postcode

* must provide value

What is the name of your placement site?

Placement start date

* must provide value

Placement end date

* must provide value

Placement Focus

* must provide value

Placement Supervisor/Contact Name

* must provide value

Placement Supervisor/Contact email address

* must provide value

University Contact (e.g. placement coordinator , unit coordinator)

* must provide value

Title of University contact (e.g. placement coordinator , unit coordinator, academic)

* must provide value

University contact email address

University contact phone number

* must provide value

Funding Type

* must provide value

Support Type

* must provide value

Cost Centre

* must provide value

Will you be seeking accommodation through the UCRH?

Yes
No

Please note you will need to make your accomodation request in the second step of the registration process