Clinical Deanery
Collaborative Health Education and
Research Centre
Bendigo Health
PO Box 126
Bendigo, Victoria, 3552
Australia
Dear student,
STUDENT MEDICAL ELECTIVE PLACEMENT – BENDIGO HEALTH
Thank you for your inquiry regarding a medical elective placement. Bendigo Health is one of
the largest regional hospitals in the state of Victoria and provides services in emergency,
surgical, maternity, women’s health, medical imaging, pathology, rehabilitation, community
services, residential aged care, psychiatric care, community dental, hospice, palliative care,
cardiology, cancer and renal services.
There are several requirements and forms that need to be completed before a placement
can be offered within Bendigo Health:
1. ‘Medical Elective Placement Application form’ – to be completed by both student
(Part A) and Dean or designate of your University (Part B);
2. National police/criminal history check from your country of residence for the past 10
years;
3. Working with children check from your country of residence for the past 10 years;
4. Copy of recent academic transcript;
5. Copy of Medical Indemnity Insurance stating student name, date of birth, student
number, placement dates and noting Bendigo Health Care Group;
6. Vaccination and immunisation records including written proof of immunisations for
TB, Rubella and Hepatitis B.
Please note, The Medical and Protection Indemnity Society (MIPS) indemnifies elective students for
free in Australia. Please follow the link below and complete the form. You will need to provide proof
of MIPS registration and acceptance before starting at Bendigo Health.
https://www.mips.com.au/Resources/Forms/student-application-form
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Costs
There are two payments required for a medical elective placement at Bendigo Health:
1. An International Bank Cheque/Draft made payable to ‘Bendigo Health – CHERC’ or
credit card payment of $AUD200 must be included with your application form for
administration fees. Please note this is non-refundable.
2. Once a placement is offered to you, we will send you a ‘Medical Elective Acceptance
of Offer’ letter which is to be signed and returned to us with an International Bank
Cheque/Draft or credit card payment of $AUD800 for the placement. This payment
is also non-refundable.
There are no further charges for the placement, however you will need to organise your
own accommodation. Bendigo Tourism has many accommodation options and can be
contacted on the following web page: www.bendigotourism.com
Please note that we will do our best to find a placement for you but we cannot guarantee
that we will be successful. I look forward to hearing from you.
Yours sincerely,
Jodie Williams
Jodie Williams
Clinical Placement Co-ordinator
Clinical Deanery/Collaborative Health Education and Research Centre
Bendigo Health
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BENDIGO HEALTH - MEDICAL ELECTIVE PLACEMENT
APPLICATION FORM
PART A: STUDENT
STUDENT DETAILS
Student name
Student address
Home phone (include international code)
Mobile (include international code)
Email
DOB
TERTIARY DETAILS
University/institution
name
Address
Course name
Current year of course
Year of course during
placement
University contact in
faculty of medicine or
equivalent
Name:
Phone:
Email:
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Clinical medical
experience you will have
completed prior to the
proposed elective
ELECTIVE PLACEMENT DETAILS
Discipline in which
clinical placement is
preferred
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
Dates (up to eight
weeks)
1. From _______________ To _______________ No weeks ___
2. From _______________ To _______________ No weeks ___
Checklist:
National Police/Criminal History Check from your country
of residence in the past 10 years
Working with Children Check from your country of
residence in the past 10 years
Copy of recent academic transcript
Copy of Medical Indemnity Insurance stating
student name, date of birth, student number,
placement dates and noting Bendigo Health
Vaccination and immunisation records
International Bank Draft for $AU200
made payable to: Bendigo Health CHERC or credit
card payment (credit card payment form attached)
English language examination form (if relevant)
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I certify that the information I have provided on this application form is complete and accurate to
the best of my knowledge. I understand that misrepresentation of information on this application
form will be deemed as sufficient grounds by Bendigo Health to withdraw its offer of placement.
_______________________________________
STUDENT SIGNATURE
__________________________
DATE
PART B: UNIVERSITY DEAN OR DESIGNATE
Student name: ___________________________________
INDEMNITY
The above mentioned student is currently registered in his/her _____________ year of a _________
year program of studies towards a Bachelor of Medicine Degree (or equivalent with the aim of
becoming a registered medical practitioner in your country).
The ____________________________________ (name of University) acknowledges that it accepts
liability for personal injury or damage to property caused by _______________________________
(Student’s name), in connection with the placement of ___________________________________
(Student’s Name) except to the extent that negligence on the part of Bendigo Health Care Group
caused or contributed to the injury or damage.
Student’s progress in the course so far:
Students knowledge of English:
Satisfactory
Unsatisfactory
Spoken
slight/good/excellent
Written
slight/good/excellent
English Language Exam
Yes
If yes, please provide exam results
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No
Dean/designate signature: ___________________________________________________________
Name:____________________________________________________________________________
Title:_____________________________________________________________________________
Name of medical school: ____________________________________________________________
Address of medical school: __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Email: ___________________________________________________________________________
University seal/stamp:
Please submit this form to:
Clinical placement co-ordinator
Clinical Deanery/CHERC
Bendigo Health
P.O. Box 126
Bendigo, Victoria, 3555
Australia
Phone:
(61) 3 5454-6394
Fax:
(61) 3 5454-6420
(if faxing this application, please forward original copies via air mail)
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Payment details
(Please select one method of payment)
International Bank Draft/Cheque
$AUD200.00
Credit Card
Visa
Mastercard
Card number:
Card expiry date:
Total amount $AUD200.00
Card holders name: ___________________________________________
Card holder’s signature: ________________________________________
Please return your payment to:
Bendigo Health
P.O. Box 126
Bendigo, Victoria, 3552
Australia
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