PERMA+ 4 & 5 November 2017

Expression of Interest

Please complete the form below to register your expression of interest for the PERMA+ program on 4 & 5 November 2017. This program is offered to SA Health employees who have four years or less of practice as a doctor, nurse or employed in allied health. 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:*

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