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Free Call: 1800 882 156
Fax: 07 3105 7801
Email: qrmfn@healthworkforce.com.au
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QRMFN Information

Would you like to:

Receive updates on upcoming events, news, and programs specifically designed to enhance your experience of life in a rural community?
Receive QRMFN’s FREE ‘Backbone’ newsletter – full of great information, stories and ideas?
Have the opportunity to apply for financial assistance to undertake that professional or personal development course you’ve always wanted to do?
Share information, ideas and experiences with others who have a common understanding?

Don't miss out - join our mailing list today!

QRMFN offers these and many other benefits to all rural medical spouses, partners and families in Queensland. Registering your details is quick and easy - just complete the relevant sections of the following form. Alternatively, you can download our Family Information Form by clicking here. We look forward to supporting you through our growing network.

QRMFN Family Information Form:

Preferred First Name*	Last Name*
Spouse/Partner of: Dr *	Country of Origin:*
Occupation:*
Email Address:*	Mobile Phone:
Home Phone:*	Fax:*
Mailing Address:*
Previous Mailing Address (for those updating details ONLY):
PART B Please indicate if you are interested in subscribing to any of the following publications offered by QRMFN by placing a tick (clicking) in the box next to the service/s you are interested in. Please note: this is NOT compulsory and you are welcome to unsubscribe at any time.
Subscribe to QRMFN’s ‘Backbone Newsletter (3 publications/year) Via post Via email	Subscribe to QRMFN e-News (email only)* Yes No
I would like QRMFN to provide my contact details to their Volunteer Representatives so that they can initiate contact with me * Yes No
Additional Information: QRMFN is also keen to include all family members in the programs and support we provide and to ensure our programs are relevant to the needs and interests of members. For this reason we are seeking the information below:
Do you have children?* Yes No
Child’s Name	Date of Birth
Child’s Name	Date of Birth
Child's Name	Date of Birth
Child's Name	Date of Birth

Thank you for registering your details with us. We look forward to networking with you!
Confidentiality Statement: The Queensland Rural Medical Family Network is committed to ensuring the confidentiality of data from individuals that complete this registration form. No personal information will be provided to external bodies or individuals that will identify the individual concerned.

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*Required

PART B