Shared Accommodation Enquiry Form

Accommodation Enquiry Form

Welcome to our Health Service!

This form is for Clinical Placement Students and Staff of Robinvale District Health Services requiring short term accomodation.
Campus*
Please choose:*

CLINICAL PLACEMENTEMPLOYEE
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DEPARTMENT:
i.e Physiotherapy, Nursing
Type of Stay:

Short StayFixed Term
Arrival Date*

DayMonthYear
Departure Date*

DayMonthYear
Time of Arrival*

Hour Minutes

AM/PM Option
NB;

Key Collection - arrival outside of business hours (8:30am-5:00pm Monday-Friday) require alternate arrangements.
Linen Required (bed linen/towels):*

YesNo
Payment via:*

Bank Transfer / EFTCashPayroll Deduction
General comment about your enquiry:
Once your enquiry form has been received, we will contact you shortly after.

Accommodation is subject to availability and is approved once an Accommodation Agreement has been signed.
Should be Empty:

Accommodation Enquiry Form