Application Form – Indigenous Placement Scholarships in the NT - Australian Indigenous Doctors' Association

Name*

First Last

Email

Phone*

Date of Birth*

Gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please indicate below whether you identify as:*

Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander

Please indicate your AIDA membership status:

I am a current AIDA member
I have submitted an AIDA member application

What university are you attending?*

What year will you graduate?*

Please indicate the type of placement:*

Clinical – NT Public Hospital (students enrolled in penultimate or final year of medical degree only)
Clinical – Remote (students enrolled in penultimate or final year of medical degree only)
Cultural Immersion

How do you currently contribute, or how will the scholarship (Clinical placement, Remote clinical placement or Cultural immersion) help you to contribute to Aboriginal and Torres Strait Islander health? (up to 200 words)*

What interests you about a clinical placement in the NT? (up to 200 words)*

Remote clinical training placement only If applying for a remote clinical placement what: a) support mechanisms (or experience to draw on) do you have in place to manage being geographically isolated from your family, cohort and friends; and b) do you hope to achieve whilst on placement?*

Other comments (optional – up to 500 words)

Consents and agreements:*

I agree to provide a 500-word article on my placement. I understand this may be used to inform relevant AIDA organizational articles, reporting and social media.
If successful in receiving the grant, I give consent to AIDA to identify me as an AIDA student member in their promotional activities.
I consent to have my personal details shared with NT PHN and AIDA
I agree to obtain appropriate approvals from my workplace and/or university, and to provide written confirmation of my placement or research from the relevant practice or institution.
I agree to report on and acquit all funds and return all funds should my placement not proceed.

Please upload your completed budget*

Insurance

Students must have current Professional Indemnity Cover and it is recommended that they take out travel insurance to cover their placement period. Professional indemnity cover can be obtained from any of the following Medical Defence Organisations (MDOs): • AVANT - Applications online or call on 1800 128 268 • MIPS - To apply, email info@mips.com.au • MDA National’s Student Indemnity Policy - Applications can be requested by calling their freecall number 1800 011 255. • MIGA

Application checklist -Please ensure you have:*

uploaded the completed budget template (available on the AIDA website)
attached letters of approval from your university and/or workplace
arranged your clinical or cultural placement

Date*