Shared Accommodation Enquiry Form

Welcome to our Health Service!

This form is for Clinical Placement Students and Staff of Robinvale District Helath Sevrvices requiring short term accomodation.
Shared Accommodation Enquiry Form

Once we receive the filed form, we will contact you shortly.
Campus *
Please choose: *

CLINICAL PLACEMENT EMPLOYEE
Full Name *

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

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

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

Short Stay (max. 3 nights) Fixed Term (max. 3 months)
Arrival Date *

Day Month Year
Departure Date *

Day Month Year
Time of Arrival *

Hour Minutes

AM/PM Option
NB; Arrivals outside of business hours (8:30am-5:00pm Monday-Friday) require alternate arrangements for key collection.
Linen Required (bed linen/towels): *

Yes No
Payment via: *

Bank Transfer / EFT Cash Payroll Deduction
Accommodation is subject to availability and will only be approved once an accommodation agreement has been signed.
Should be Empty: