WILDFIRE MEMBERSHIP APPLICATION FORM

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Please complete the form below to become a member of WILDFIRE (Working In Leading Development For Indigenous health and Rural Education). You will be able to attend educational and social events in the future and receive updates on all things WILDFIRE!

* Denotes a mandatory field - your membership cannot be created if you do not provide the mandatory information.

Wildfire 2020 Sign Up

First Name *

Last Name *

Student Number *

Email Address *

Date of Birth *

Gender *

Male

Female

Other:

Clear selection

You identify as *

Aboriginal

Torres Strait Islander

Aboriginal/ Torres Strait Islander

None of the Above

Clear selection

Mobile Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Do you have a rural background? *

Yes

Clear selection

Course Name *

Pharmacy

Pharmaceutical Science

Other:

Year of Expected Completion *

Do you intend to work in a rural area in the future *

Yes

Unsure/Maybe

Clear selection

You see yourself working in:

City

Regional

Rural

Remote

Unsure

Clear selection

Submit

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