AMC Clinical Bridging Program Application Form 2013.1South Australia (Adelaide)

Clinical Bridging Program /

Series 1

Commencement date:
Friday, March 15th
Trial exam–Saturday, 17th 2013
2. Where did you first hear about our Bridging Programs?
RACGP/gplearning Website
Hospital/University notice
Indian Link Newsletter / Recruitment Agency
Friday Facts
Doctor Connect Website / Australian Medical Council
Medical Careers Expo
Word of Mouth – Please Specify
------
3. Participant Details
Family name
First Name / Other Names
Preferred Given Name
Mailing Address  Home  Work  other
State / Postcode
Phone No: (Home) / (Work) / mobile
Fax No /  home  work / e-mail
 Male  Female / Date of Birth / / / Country of Birth
4. Emergency Contact
Contact Person ______/ Phone No ______
5. Qualifications
University of graduation (please include country)
______ / Qualification
______/ Year of completion
______
6. Clinical Consulting Skills
Have you ever attempted the AMC Clinical Consulting Skills examination? / Yes  No 
If yes, please indicate the year in which you last sat the exam? / ……………………
Please indicate the number of attempts / 1 / 2 / 3 / 4 / 5+
7. Medical work experience
Could you briefly describe your previous and / or current medical work experience:
______
______
8. Dietary Requirements
Could you please tick () which meal choices you enjoy
Meat / Vegetarian / Please specify any allergies: e.g. Peanuts/Gluten free:
Are there any meats that you cannot consume for dietary or religious reasons?
9. Code of Conduct
Participants of the RoyalAustralianCollege of General Practitioners (RACGP) AMC Bridging Program and the staff of the RACGP are expected to adhere to appropriate standards of workplace behaviour. Program participants have a right to study in an environment free from intimidation or harassment. The ground rules communicated at the beginning of the program by the Educator must be adhered to. We expect you to conduct yourself as a professional and behave courteously towards other class members and staff.
If objectively, a participant becomes ‘unduly disruptive’* and disrespectful of others; the Medical Educator will give the person a verbal warning. If the person persists with this behaviour they will be asked to leave the building. The Medical Educator will report the situation to the Program Manager. It is in the discretion of the Program Manager whether this person will be permitted to continue to participate in the program sessions.
The RACGP reserves the right to refuse a person, who has previously been asked to leave a program, to participate in any future programs run by the RACGP in Australia
*For the purposes of this Code of Conduct, ‘unduly disruptive’ may mean that the participant interferes with the class progressing at an acceptable pace. It may mean something less than such as unreasonably interjecting during classes, or argumentative, or aggressive conduct which impedes rational discussion or offends other program participants. This illustration of unacceptable behaviour is to provide guidance only and is not attended to be an exhaustive definition of the terms used.
10. Minimum Number Requirements
The program requires a minimum number of participants to run. If we do not reach our minimum number of participants for a program, the program may have to be cancelled.
11. Payment
Payment of Course Fee in FullUpfront– This Payment can be made via Credit Card, Bank Cheque or Money Order.
Please complete the Full Payment Form on page 4 of this application form.
Payment of Course Fee in Instalments – This payment can be made via Credit Card only. Full payment must be received before the course commences.
Please complete the Instalment Payment Form on page 5 of this application form
Details of the Instalment Plan
An initial payment for $995 is payable when the Application Form is forwarded to the RACGP.
A second Instalment of $2,500 will be deducted from your credit card on the date stated in the instalment table on the Instalment Payment Form (Page 4).
The last instalment of $2,500 will be deducted from your credit card on the date stated in the instalment table on the Instalment Payment Form (Page 5).
By signing the payment form, you acknowledge that you have given permission to the RACGP to deduct the second and third instalments when the payments are due.
By signing the payment form, you acknowledge that you have given permission to the RACGP to create a payment form to deduct the second and third instalments when the payments are due.
Please be aware that if the last instalment cannot be deducted successfully before the course commences, you will not be able to attend the course. Once the course has commenced, late payments will not be accepted.
Please call us if you wish to discuss this further.
12. Cancellation/Withdrawal Policy
A full refund of the registration fee will apply provided that written notice is received by the RACGP no later than two(2) weeks prior to the start of the workshop date.
If a participant, whether paying full fee upfront or in instalments, cancels their registration less than two (2) weeks prior to the start of the workshop date, the RACGP will deduct 10% of the full registration fee.
If the RACGP is unable to deduct the last instalment of the registration fee less than two (2) weeks prior to the start of the workshop date, the RACGP will refund monies already received minus 10% of the full registration fee.
If a participant transfers their application to another series less than two (2) weeks prior to the start of the workshop date, the RACGP will deduct a 10% administration fee.
If a participant cancels their registration during the program, there will be no refund.
If a participant cancels their Trial Exam registration less than one (1) week prior to the trial exam date, and wishes to transfer to another trial exam date, they will be charged 10% of the trial exam only registration fee.
The Registrant acknowledges that the cancellation fee is not a penalty but a genuine pre-estimate of the loss and administrative consequences caused by late cancellation
13. Declaration
I understand:
  • the offer of a place in this program is not guaranteed as it is subject to state quotas
  • participation in this program does not guarantees success for AMC candidates with respect to any AMC Examination Process
I agree to abide by the Code of Conduct as outlined in Section 11 on this application form
I have read and understand the terms of the Cancellation/Transfer policy in Section 12 on this application form.
Signature______Print Name______Date ______
14. Checklist
Please ensure that you have completed / attached the following:
ELIGIBILITY AND SUPPORTING DOCUMENTATION REQUIRED
Clinical Consulting Skills Program Candidates:
Copy of your MCQ results indicating you have passed.
If arriving from overseas, or not a permanent resident of Australia, we require a photocopy of your immigration Visa that you have been granted. All immigration Visas must be valid for the entire duration of the bridging program or we are unable to accept your registration.
Please note: We are unable to hold places for overseas residents who have not been granted a visa or are awaiting a visa.
Copy of either your Occupational English Test (OET - Academic) or the International English Language Testing System (IELTS), indicating your average result (an OET overall B grading or a Band 6.5 with no score below 6 in the IELTS system) or a letter of exemption from the AMC. When applying to sit the Australian Medical Council Exam, please check the AMC website as to the English language test requirement.
Payment Form with Payment
It is mandatory that on the first day of the bridging course commencement all participants arriving from overseas must provide the RACGP with Australian contact details including an address and mobile phone number.
It would be advisable to take a copy of this form for your records and to keep a copy of the contact details:
Contact details:
AMC Bridging Program, RACGP National Office, 100 Wellington Parade,
East Melbourne, VIC 3002
Email: ; Fax:(03) 8699 0588
Enquires Please call 1800 284 732

Full Upfront Payment Form/Tax Invoice

AMCClinical Bridging Program 2013.1

Applicant Details
First Name : / Family/Last Name :
Address :
Post Code : / RACGP NO.
( if known )
Please Select Program Series / Program Description /

Cost

2013.1 / AMC Clinical Bridging Program
( Including Trial Exam ) / $5,995
Trial Exam Only ( where places are available ) / $682
Payment Details
  • Cheque or Money Order
(made payable to “RoyalAustralianCollege of General Practitioners”
or “RACGP”)
  • Visa  Master Card  AMEX
Card No: _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _ Expiry Date: _ _ / _ _
Cardholder Name: (As it appears on the credit card) ___
Signature: Amount: ___
Your enrolment for all RACGP Bridging Programs and Trial Exams for International Medical Graduates cannot be secured until payment is received.
Applicants are advised to consult their financial adviser on the tax benefits available for engaging in vocational training and education.
Please forward your Application form, supporting documents and payment by post, email or fax to:
AMC Bridging Program, RACGP National Office, 100 Wellington Parade, East Melbourne, VIC 3002
Email: ; F:(03) 8699 0588
Enquiries: Please call 1800 284 732
APPLICATIONS & FULL PAYMENT MUST BE RECEIVED 2 WEEKS PRIOR TO THE COMMENCEMENT OF THE PROGRAM
FOR OFFICE USE ONLY
RACGP No (Bill To)
/ Batch No
/ Order No / Invoice No

1

Instalment Payment Form/Tax Invoice

AMCClinical Bridging Program 2013.1

Applicant Details
First Name : / Family/
Last Name :
Address :
Post Code : / RACGP NO.
( if known )
Please State series / Program Description / Total Cost
2013.1 / AMC Clinical Bridging Program
( Including Trial Exam ) / $5,995
Date of Instalment /

Instalment Amount

With Application form / $995
February 4th, 2013 / $2,500
March4th, 2013 / $2,500
Payment Details
By credit card
  • Visa  Master Card  AMEX
Card No: _ _ _ _/_ _ _ _/_ _ _ _/_ _ _ _ Expiry Date: _ _ / _ _
Cardholder Name: (As it appears on the credit card) ___
Signature: Amount: $995
Your enrolment for all RACGP Bridging Programs and Trial Exams for International Medical Graduates cannot be secured until payment is received.
Applicants are advised to consult their financial adviser on the tax benefits available for engaging in vocational training and education.
Please forward your Application form, supporting documents and payment by post, email or fax to:
AMC Bridging Program, RACGP National Office, 100 Wellington Parade, East Melbourne, VIC 3002
Email: ; F:(03) 8699 0588
Enquiries: Please call 1800 284 732
APPLICATIONS & FULL PAYMENT MUST BE RECEIVED 2 WEEKS PRIOR TO THE COMMENCEMENT OF THE PROGRAM
FOR OFFICE USE ONLY
RACGP No (Bill To)
/ Batch No
/ Order No / Invoice No