Pre Hospital Trauma Life Support

Registration Form

If you require assistance please call 07 3636 6208 Mon-Fri


1st choice for PHTLS Course
2nd choice for PHTLS Course  
*I give permission for my initial & surname to be placed on the PHTLS internet class roll
 Yes        No    
    *Required Fields
CONTACT DETAILS       
*Mr / Ms / Dr /Prof:
*First Name:
* Surname:
Preferred Name on Certificate:
Mobile:
* Telephone:
Email:
* Postal Address for pre-course reading material & correspondence
* Suburb:
* State:
   * Postcode:

Click the button on the left of appropriate employment area. - Complete and continue application. (*Required Field)

CLICK HERE
I AM A QUEENSLAND HEALTH STAFF MEMBER / Including Medical Students
*Stream:
    QH Staff No.
Medical Student at :
   Student No. 
Other University:

*Health District:
Other:
*Current Department:
*Job Title/Level:
Please choose one of the payment options below
 
Option 1: I will be paying $450 for my course via:
VISA    Cheque    Mastercard   
Option 2: My District is paying $450 for my course:

Authorised expenditure approval officer's name:
Authorised expenditure approval officer's contact number:
CLICK HERE
I AM FROM A NON-PROFIT ORGANISATION / Including Emergency Services
*Professional Title:
Current Organisation:
*Current Department:
*Job Title:
Please choose one of the payment options below
 
Option 1: I will be paying $550 for my course via:
VISA    Cheque    Mastercard   
Option 2: My Department is paying $550 for my course:
 
Name of Payee:
Contact number for Payee:
I AM FROM AN OUTSIDE ORGANISATION / Including Australian Defence Force
*Professional Title:
Current Organisation:
*Current Department:
*Job Title:
Please choose one of the payment options below
 
Option 1: I will be paying $750 for my course via:
VISA    Cheque    Mastercard   
Option 2: My Company/Organisation is paying $750 for my course:
 
Name of Payee :
Contact number for payee:
AWARENESS *
How did you hear about this course?
ACCESS AND EQUITY INFORMATION *
*The Skills Stations on the PHTLS course are very physical and require full participation. Do you have any physical limitations?:

 Yes        No

 Back      Knee     Recent surgery       Pregnant

Other:  

Do you identify as Aboriginal or Torres Strait Islander?:
 Yes        No
*Do you require an interpreter?:
 Yes        No
If 'yes' please specify language:
*Would you like to receive additional help in literacy or numeracy while participating in this course?:
 Yes        No

*Have you previously participated in a PHTLS Course?:

 Yes        No     
Year and Location  

*Any special dietary needs?:
INFORMATION GIVEN TO INSTRUCTORS PRIOR TO PARTICIPATION
Specialty:
Years Since Qualified:
Years of Training:
Years of Fellowship:
  PREVIOUS AND ONGOING STUDY
*Professional development undertaken within the last 2 years:
*Professional qualifications:
*Current study being undertaken:
PROFESSIONAL DEVELOPMENT
Commonwealth Procedurals Grant
 Yes        No
Name of College:
Membership Number:
 

Please ensure all details are correct
Press 'Continue' button below only ONCE to automatically submit Registration Form