Note: This is not an application form. This is an Additional Information Form to support your Application for Admission. Your application cannot be considered until Admissions receive this Additional Information Form.

If you have not done so, you must also apply for admission via the ACU online application.

• This additional information form is to be submitted by all Master of Health Science (Clinical Practice) applicants. Please note your Application for Admission will not be processed until this (and any supporting documentation) is received.
• Late applications may be considered. Please contact Course Coordinator Dr Rosemary Ford (03) 9953 3180 or rosemary.ford@acu.edu.au

First name

Surname

Student ID number

Date of birth

Phone

Email address

Current field of nursing practice

Number of years in this specialty practice since registration

1234other

Hospital at which you are currently employed

Are you able to undertake your practical units at this hospital?

•  Yes
•  No

Indicate which speciality strand you wish to study

Aged CareAnaestheticsCardiac CareCardiothoracicChild & Adolescent HealthDementia CareEmergencyIntensive CareInterventional CardiologyJustice HealthMedicalNeonatal CareNeurosciencesOncologyOphthalmologyOrthopaedicsPalliative CarePerioperativePlastics/OrthopaedicsPlastics/ReconstructionRehabilitationRenalSurgicalUrology