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E-mail Address

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Secondary Email

Birth Date

Mobile Number

Rural Health Club (find your university HERE).

Gender

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Do you consider yourself as having a rural or remote background?

Do you intend to work in a rural area in future?

Do you identify as Aboriginal or Torres Strait Islander?

Where did you lived prior to commencing your degree

Are you an international or domestic student?

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Education

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Previous Study

University

Student ID Number

Year of expected graduation

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