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Students

North West Student Accommodation Request Form

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)
  • Proof of completion of cultural competence training (see information below)
  • Completed and signed JCU Talent Release form (link to download form below).

Murtupuni JCU's preferred cultural competence training is Western Australian Centre for Rural Health's Cultural Orientation Plan for health professionals working with Aboriginal people. Please access this training via the link below.

Cultural Orientation Plan for health professionals working with Aboriginal people

JCU Talent Release Form

Student Contact Details

Surname
First name
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 *
Mount Isa
Cloncurry
Karumba
Burketown
Normanton
Dajarra
Boulia
Select all that apply.
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

Are you currently studying in a Commonwealth Supported Place (CSP)? *
Yes
No
Proof of CSP eligibility is required to be uploaded with this form before confirmation of accommodation can be provided.
Please upload your proof of CSP.
Or drag and drop file here
Please upload your certificate of completion of cultural competence training. *
Or drag and drop file here
Please upload your completed and signed JCU Talent Release form. *
Or drag and drop file here
Are you an international student? *
Yes
No
Unfortunately, we are unable to provide international students with accommodation.
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

A Commonwealth funded Department of Rural Health
in collaboration with: