TRICS registration form

Applicant Name:    Enter here

Employee Number:  Enter here

Email address:        Enter here

Mobile Number:       Enter here

Unit/Department: Enter here

Please indicate if you are BLS or ALS accredited:       Enter here

 VISA     ☐

MASTERCARD     ☐

CHEQUE     ☐

CARD NUMBER  

AMOUNT: $25.00

Expiry Date:    Enter date

CCV number: Enter here

Card holder name: Enter here

Signature: Enter here

Date:  Enter here

Registration

Complete this form and return it to EducationEnquiries@nh.org.au

Payment Details:

Terms & Conditions

·          All fields must be completed

·          No cash payments accepted

·          Payments will be processed after the registration closing date

·          No refund after the closing date. Credit will be used for future study day.

·          Payment will appear on statement as NH Medical Services

·          Northern Health will make every attempt to provide the program as outlined, however reserve the right to change or cancel the program. 

·          Contact EducationEnquiries@nh.org.au or 8468 0751 if you have not received an email within 1 week of sending your registration form

·          Study leave needs to be approved by the applicant’s manager and can NOT be processed by Northern Health Education (Study Leave does not guarantee a place)

Forms not filled in correctly or handwritten will be returned