PERMA+ – 8-9 October 2016 (Medical Practitioner)

Expression of Interest

Please complete the form below to register your expression of interest for the PERMA+ program on 8-9 October 2016. 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:

Hospital/DOH:*

Department:*

Postal information

Home address:*

Suburb:*

State:*

Postcode:*

Contact information

Mobile phone:*

Pager number:

Dietary requirements? Please specify:*

Do you have any disabilities that we should be aware of? Please specify:*

How did you hear about the program:*

Emergency contact

Emergency Contact - Full name:*

Emergency Contact - Phone number:*

Word Verification:

PERMA+ – 8-9 October 2016 (Medical Practitioner)

Education & Training