Professional Development Program for Registrars (PDPR) 16-17 November 2017

Please enter your information in the form below for the Professional Development Program for Registrars from 15–16 November 2017.

Please note that as this is a two-day (non residential) workshop, commitment to both days is mandatory. When applying for the PDPR, please advise your supervisors that two days of shift coverage is required.

Please note this program is offered only to SA Health employees, the 'employee number' is proof of your employment.

First name:*
Last name:*
Preferred name:
Title:*
E-mail:*
SA Health Employee Number:*
Gender:*
Position title:*
Hospital*
Department:*
Year:*
Postal information
Home address:*
Suburb:*
State/Territory:*
Postcode:*
Contact information
Mobile phone:*
Work phone:
Pager number:
Dietary requirements? Please specify*
Do you have any disabilities that we should be aware of? Please specify:
Have you organised approved leave to attend this program?*
How did you hear about the program:*
Name of referrer (if applicable):

Supervisor contact details

Supervisor full name:*
Supervisor email:*
Emergency contact
Full name:*
Phone number:*
Word Verification: