PHRM Training Program Enrolment Form

  • PHRM Training Program Enrolment Form

    Please apply in the form below.
  • Is this your preferred name?*
  • Gender*
  • Date of Birth*
     / /
  • Is your postal address the same as above?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you of Aboriginal or Torres Strait Islander origin?*
  • Are you descended from a Māori (that is, did you have a Māori birth parent, grandparent or great-grandparent, etc)?*

  • Professional Details

  • Do you hold appropriate registration with the relevant regulatory body as applicable for the jurisdiction in which you are intending to train?*
  • Select the medical board/s you are registered with:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you a Fellow or trainee of ACEM, ACRRM, ANZCA, CICM or RACGP?*

  • Please Note: there is a requirement that trainees have not more than 18 months of required training to complete in order to be eligible to attain Fellowship.

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  • Prospective PHRM trainees must be a Fellow or trainee of ACEM, ACRRM, ANZCA, CICM or RACGP. All other applications will be assessed on a case-by-case basis by the Conjoint Committee of PHRM. Please contact a member of the ACEM PHRM team to discuss your specific circumstances at PHRM@acem.org.au.

  • Which college do you belong to?*

  • Format: (000) 000-0000.
  • Have you applied for RPL/RPE prior to your PHRM enrolment?*

  • Prospective PHRM Training Site Placements

  • You must complete at least 6 FTE months of training time to meet your PHRM Training Program requirements.

    Please detail your prospective training time below.

    Note:

    • Training may be undertaken in blocks of not less than 3 months FTE at a time.
    • You must complete 6 FTE months of PHRM training time within 3 years of your enrolment date.
    • If your nominated site is only accredited for the Pre-Hospital component of the PHRM Training Program, then you must also complete time at a site accredited for the Retrieval component of training.
    • If your nominated site is only accredited for the Retrieval component of the PHRM Training Program, then you must also complete time at a site accredited for the Pre-Hospital component of training.  

  • Position One

  • Start Date*
     - -
  • End Date*
     - -

  • Position Two

  • Start Date*
     - -
  • End Date*
     - -

  • Position Three

  • Start Date*
     - -
  • End Date*
     - -

  • Position Four

  • Start Date*
     - -
  • End Date*
     - -

  • PHRM Placement and Training Supervisor Details

  • Evidence of a confirmed training position at a site accredited by the Conjoint Committee of Pre-Hospital and Retrieval Medicine (CCPHRM) for PHRM training is required. This evidence must also specify the name of your PHRM Training Supervisor. Your primary supervisor must be a Fellow of ACEM, ACRRM, ANZCA,CICM or RACGP who is an approved PHRM Training Supervisor. This evidence can be provided in the following formats; letter from empoyer, letter from PHRM Training Supervisor, or completed CCPHRM-approved pro-forma letter. Please upload this evidence.

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  • Enrolment Fee and Applicant Declaration

  • If your application is approved, you will be invoiced the PHRM enrolment and training fee. Please note that the enrolment and training fee is separate from any examination fees which will incur an additional cost. The enrolment and training fee must be paid prior to commencement of a trainee’s PHRM placement. More details on fees can be found on our website here.

    Trainee Agreement
    Applicants enrolling into the PHRM Training Program are required to view the Trainee Agreement and declare that they will abide by the obligations specified within. Click here to view the PHRM Trainee Agreement

  • Date*
     - -
  • How did you hear about the PHRM Training Program?*

  • What is your main reason for enrolling in the PHRM Training Program?*

  • Should be Empty: