2021 Major Incident Medical Management Support (MIMMS)
Metropolitan Course Application Form

All application forms with employer funding require a signature from your authorising officer/manager

Electronic signatures will NOT be accepted

Step 1	Participant to complete section 1 & 2 (and section 4b, if self-funding) of this form.

Step 2	Print and provide to manager or authorising officer for completion of sections 4 & 5 – including signature.

Step 3	Scan signed application form and email to DPMUTraining@health.wa.gov.au

SECTION 1: Course Selection

Course	Closing Date	Location	Govt. Rate	All Others
MIMMS Team Member	17 Feb 2022	6 Jan 2022	Perth	☐ $150	☐ $195
MIMMS Advanced	23 – 25 Mar 2022	11 Feb 2022	Perth	☐ $695	☐ $995
MIMMS Team Member	5 May 2022	24 Mar 2022	Perth	☐ $150	☐ $195

Govt. Rate: Applies to applications funded by the WA Department of Health, associated emergency response partners (i.e. SJA, DFES, WAPOL, and Defence), publicly contracted hospitals (Peel, JHC, SJOG, MPPH) and self-funded WA Department of Health employees.
All others: Applies to anyone not in the above categories.

SECTION 2: Applicant Information

(* denotes required field)

Title	First Name*
Preferred Name	Surname*
Employer*	Department
Occupation*	Work Region
Work Phone	Mobile Phone
Postal Address*
Course manuals will be posted to the address provided above.
Email Address*
All course communications will be provided to the email address provided above.
Do you have any special learning requirements? (E.g. large print, wheelchair access, etc.)
☐ No	☐Yes (please provide details)

Diet*	Do you have any special dietary requirements?	Nil ☐

Vegan ☐	Vegetarian ☐	No Pork ☐	No Red Meat ☐	Diabetic ☐	Coeliac	☐

Other:	Allergies:

Note: We endeavour to cater for specific allergies, intolerances and cultural dietary requirements. Unfortunately, personal preferences cannot be catered for, as this often incurs additional costs.

I confirm that: *

☐ I confirm that all information I have provided in this form is accurate.

☐ I confirm that I am aware of section 4 of this form and of the course dates and costs.

☐ Failure to provide more than 10 working days’ notice of a non-attendance will result in full costs being incurred under the below authority.

Signature of applicant: __________________________________________________	Date: _______________

(Note: If applicant self-funding course, please complete section 4b)

SECTION 4: Payment Details

The cost of the course will be covered by: *

☐ Journal Transfer (complete section 4a) ☐ Agency or applicant by invoice (complete section 4b)

(Note: applications will not be accepted without payment information and authority completed)

4a – ☐ Department of Health Cost Centre (* denotes required field for journal transfer payment)

Entity #*	Cost Centre #*
Account #*	Amount*
Approval Officer*	Approved by Approval Officer*	☐ Date: Click or tap to enter a date.
Contact Number*	Email Address*

OR

4b – ☐ Payment by Invoice (* denotes required field for invoice payment)

Payer Name*	Purchase Order #
Position/Title	Email Address*
Address*	Contact Number*
Suburb*	State*	Postcode*

SECTION 5: Management/Authorising Officer Approval

(* denotes required field)

Title	HE #(Health Staff) *
Full Name*	Email*
Position*	Department
Organisation*	Contact Number*

I confirm that: *

☐ I support this application and will release the applicant from duty as stipulated.

☐ Failure to provide more than 10 working days’ notice of a non-attendance will result in full costs being incurred under the below authority.

☐ I confirm that the payer or approval officer named in section 4 are aware of and approve of the course fees.

Signature of Manager/Authorising Officer: _________________________________________	Date: _____________

(note: electronic signatures will NOT be accepted)

Notes:

All relevant payment details must be completed for application to be considered.

Successful applicants will be notified approximately 4 weeks prior to the course via the email address provided.

If you require notification of successful application more than 4 weeks prior to the course, please contact the DPMU Training team.

Please scan completed application form and email to DPMUTraining@health.wa.gov.au

in order for your application to be considered. 3