VAHPA Training Registration 2017 Question Title * 1. Your details. First Name Family Name Mobile Non-work Email Profession Question Title * 2. Primary Employer NB. If your primary Employer is other than the Public Sector or Community Health, please select 'other' and enter details in the field below. Access Health & Community Albury Wodonga Health Alexandra District Hospital Alfred Health Alpine Health Austin Health Bairnsdale Regional Health Ballarat Health Ballarat Community Health Banyule Community Health Barwon Health Bass Coast Regional Health Beaufort & Skipton Health Service Bellarine Community Health Benalla Health Service Bendigo Health Bendigo Community Health Bentleigh Bayside Community Health Carrington Community Health Calvary Health Castlemaine Health Castlemaine District Community Health Central Bayside Community Health Central Gippsland Health Cobaw Community Health Cobram District Health CoHealth Cohuna District Health Colac Area Health Darebin Community Health Dental Health Service Dianella Community Health Djerriwarrh Health Service Dunmunkle Health Service EACH East Grampians Health East Wimmera Health Service Eastern Health Echuca Regional Health Edenhope & District Memorial Hospital Gateway Health Gippsland Lakes Community Health Gippsland Southern Health Service Goulburn Valley Health Grampians Community Health Health Ability Heathcote Health Hepburn Health Service Hesse Rural Health Service Heywood Rural Health Inglewood & District Health Service Inner South Community Health Inspiro IPC Kerang District Health Kilmore & District Health Kooweerup Regional Health Service Kyabram & District Health Service Kyneton District Health Service Latrobe Community Health Latrobe Regional Hospital Link Community Health Lorne Community Hospital Maldon Hospital Mallee Track Health & Community Service Mansfield District Hospital Maryborough District Health Service Melbourne Health Mercy Health Merri Community Health Mildura Base Hospital Monash Health Mayne Health Service Natalia District Hospital Nexus Primary Health Northeast Health Wangaratta North Richmond Community Health Northern District Community Health Northern Health Numurka District Health Service Omeo District Health Orbost Regional Health Otway Health & Community Service Peninsula Health Peter Mac Plenty Valley Community Health Portland District Health Primary Care Connect Robinvale District Health Service Rochester & Elmore District Health Service Royal Children's RVEEH Rural Northwest Health Seymour Health South Gippsland Hospital South West Healthcare St Vincent's Stawell Regional Health Sunbury Community Health Swan Hill District Health Tallangatta Health Service Terang & Mortlake Health Service Timboon & District Health Care Service Upper Murray Health & Community Services West Gippsland Healthcare Group Western Health Wimmera Health Care Group Yarram & District Health Service Yarrawonga District Health Service Yea & District Memorial Hospital The Women's Other (please specify) Question Title * 3. Please indicate which of the following VAHPA Delegate Training courses you wish to attend? Aug 31 & Sep 1 Oct 24 & 25 VAHPA use only Question Title * 4. If you are a regional Delegate, which night(s) will you require accommodation for ... (NB If you are unsure at this stage an estimate is ok - we can confirm later on) The night prior to day 1 The night between days 1 & 2 Both the night before day 1 and the day between days 1 & 2 Neither - I have accommodation in Melbourne Other (please specify) Question Title * 5. Do you have any dietary requirements or restrictions? No Yes - Please specify Question Title * 6. T-Shirts. Please indicate your preferred t-shirt size for your new Delegate photo Small Medium Large Extra Large 2XL 3XL 4XL 5XL Question Title * 7. Do you have any questions? Question Title * 8. Office Use Only 1 - Letter & confirmation emailed Other (please specify) Done