NLDS Application Form

AMSA RACGP National Leadership Development Seminar 2008

Please complete the application form below if you wish to apply to attend the 2008 AMSA RACGP NLDS. Applications will be short listed by representatives from your local Medical Student Society. Final selections will be made by a panel appointed by the AMSA Executive.

Applications close on 1 August 2008. Successful and unsuccessful applicants will be notified by email on 11 August 2008. If you have any questions about the NLDS application or selection process please contact ico@amsa.org.au. Good luck!

PERSONAL DETAILS

These details will be used for contact and demographic purposes only and will not be used in the selection process.

First Name

Surname

Preferred Name (for badge)

Gender

Date of Birth / MM / DD YYYY

Home Phone

Mobile Phone

Email

Confirm Email

Term Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Mailing Address (if different to above)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

University

Graduate/Undergraduate

Year Level

Entry Type

Emergency Contact Person

Emergency Contact Number

Please specify any medical conditions you think we should be aware of:

Please specify if you have any specific dietary requirements:

My name and contact details can be provided to other 2008 AMSA RACGP NLDS delegates for networking purposes:

TRAVEL AND ACCOMMODATION ARRANGEMENTS

If you receive a place at the 2008 AMSA RACGP NLDS flights will automatically be booked for you. We will be flying delegates in to Canberra all day on Sunday 31 August and on the morning of Monday 1 August, depending on flight cost and availability (NB Travel will not be arranged for ANU Students of for New Zealand Applicants). Special travel arrangements will only be made in exceptional circumstances.

Please comment below if you have special travel requirements:

QANTAS Frequent Flyer Number:

Virgin Blue Velocity Number:

If you receive a place at the 2008 AMSA RACGP NLDS accommodation will automatically be booked for you. Accommodation will be 5 or 6 share with other delegates. In order to facilitate networking we will preferentially accommodate delegates in rooms with delegates from other Universities.

Please comment below if you have special accommodation requirements, or if you will not require accommodation in Canberra.

If I make changes to my travel arrangements or withdraw from the 2008 AMSA RACGP NLDS I agree to cover the costs associated with changing or cancelling my flights. Yes

TERMS AND CONDITIONS

Please read the AMSA Event Terms and Conditions for Delegates here.

I agree to AMSA Event Terms and Conditions for Delegates. Yes
Compulsory Field

SELECTION CRITERIA

Leadership Qualifications

Please describe your past and/or current leadership experience. Include details of your involvement and the roles/tasks you have fulfilled as well as the skills you have gained. (400 word limit).

Please detail your future plans with respect to leadership within and beyond the medical student community. (400 word limit).

What leadership experience and/or skills do you hope to gain from the 2008 AMSA RACGP NLDS? (400 word limit).

Why are you a good candidate for the 2008 AMSA RACGP NLDS? (400 word limit).

Current Issues in Health & Education

What do you believe are the three (3) most important issues facing medical students today? Issue 1

Issue 2

Issue 3

Please briefly describe one (1) of these issues and why you believe it is important (200 words).

Please list three (3) major health issues in Australia that you believe medical students and their representative bodies (AMSA, state medical student councils, local medical student societies) should be addressing today? Issue 1

Issue 2

Issue 3

Please briefly describe one (1) of these issues and why you believe it is important (200 words).

REFEREES

Please provide the details for up to two referees. At least one should be related to the medical field (eg. medical student society Executive member (past or present), member of the medical faculty, clinical mentor/tutor etc).

Referee 1 Name

Position/Occupation

Daytime Contact Phone

Email

Referee 2 Name

Position/Occupation

Daytime Contact Phone

Email

(c) 2005 - 2008 Australian Medical Students' Association