NARN
NARN IAHA
JCU Centre for Rural & Remote Health
    More
    circle

    North West Student Accommodation Request Form

    Quicklinks

    Home
    Students
    Student Placements
    North West Student Accommodation Request Form

    Pages in this section:

      This form is for students who will be attending their rural clinical placement in Murtupuni JCU's North West region.

      To submit this form, you will need the following:

      • Proof that you are enrolled in a Commonwealth Supported Place (CSP)
      • Completed and signed JCU Talent Release form (link to download form below).

      JCU Talent Release Form

      Student Contact Details

      First name
      Surname
      Residential Address
      Postal Address If different to above
      Mobile phone number
      Student email address

      Emergency Contact Details

      Name
      Phone number Please include area code if outside Queensland

      Placement Details

      Placement Location/s *
      Mt Isa
      Cloncurry
      Burketown
      Karumba
      Normanton
      Dajarra
      Boulia
      How will you be travelling to your placement location? *
      Flying
      Driving
      Although accommodation locations are within walking distance to placement locations, having your car is handy when working shifts, exploring the region and generally getting around.
      Placement start date
      Placement end date
      Total Placement weeks
      Student number
      University
      Discipline
      Other (if your discipline is not listed above)
      Please indicate your student status *
      Undergraduate
      Postgraduate
      Intern
      Current year of study

      University supervisor details

      Supervisor name
      Supervisor role/position title
      Supervisor email
      Supervisor Phone

      Student information and eligibility

      Please upload your proof of CSP. *
      Please upload your completed and signed JCU Talent Release form. *
      Do you identify as Aboriginal and/or Torres Strait Islander and/or South Sea Islander? *
      Yes
      No
      Do you have a medical condition that the JCU MCRRH student accommodation team should be aware of? *
      Yes
      No
      If yes, please call Murtupuni JCU accommodation team on 07 4745 4500.
      Do you wear a medical bracelet? *
      Yes
      No
      Did you primarily live in a rural or remote town growing up? *
      Yes
      No
      Note: Rural/Remote origin is defined as “residency for at least 10 years cumulatively or any 5 years consecutively in an ASGS-RA 2-5 area since the age of five years.” 
      I acknowledge that by submitting this form, I confirm the information provided is accurate. I understand this constitutes a tentative booking for student placement accommodation with Murtupuni Centre for Rural and Remote Health, which will only be confirmed upon receipt of a completed this Student Accommodation Request Form in its entirety. *
      I agree

      Navigation

      Social

      A Commonwealth funded Department of Rural Health
      in collaboration with:

      Logo Logo Logo Logo Logo Logo Logo Logo Logo Logo