2022 Major Incident Medical Management Support (MIMMS)
Regional Course Application Form

All application forms require a signature from your manager

Step 1	Participant to complete section 1 & 2 (and section 3 for private company applicants) of this form.

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

Step 3	Email signed application form to DPMUTraining@health.wa.gov.au

SECTION 1: Course Selection

Course	Date	Location	Course date preference	Govt. Rate	All Others
MIMMS Team Great Southern	10th or 11th February 2022	Albany	☐ 10th	☐ 11th	☐ Free	☐ $195
MIMMS Team Midwest	9th or 10th March 2022	Geraldton	☐ 9th	☐ 10th	☐ Free	☐ $195
MIMMS Team Goldfields	20th or 21st April 2022	Kalgoorlie	☐ 20th	☐ 21st	☐ Free	☐ $195
MIMMS Team Pilbara	12th or 13th May 2022	Hedland	☐ 12th	☐ 13th	☐ Free	☐ $195
MIMMS Team Wheatbelt	16th or 17th June 2022	Narrogin	☐ 16th	☐ 17th	☐ Free	☐ $195

Note: Course dates may be subject to change dependant on applicant numbers.

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*
Occupation*	Department
Employer*	Region*
Facility/hospital*	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.

SECTION 3: Payment Details (if required)

The cost of the course will be covered by: *

☐ Nil Fee (Course is free nil payment info required)	☐ Private Agency or Applicant by invoice (complete below)

(Note: Course payment information must be completed)

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

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

SECTION 4: Manager 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.

Signature of Manager: _________________________________________	Date: _____________

Notes:

All relevant payment details (if required) 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