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Central Adelaide Local Health Network Mental Health Directorate For more information Annette Farrell Administration Assistant Learning Centre Tel: (08) 7087 1800 (Monday – Thursday) Fax: (08) 7087 1930 Email: [email protected] Other: Place of employment: Department / Ward / Team: Postal address: Telephone: Email: The Learning Centre Application Form Course Information Course Title: Course Date: Registrant Information Given name: Surname: Professional information Course Time: Date of Birth: Payroll No: HAD ID: Mobile: Payment Details: (Individual or Department Responsible for Payment) A $35.00 cost for MAPA (Full Day and Refresher) Workbooks and a $45 cost for MAPA (Advanced) Workbooks applies. Please provide details below of the person / department to be invoiced for payment. Person / Department Responsible for Payment: Email: Department / Ward / Team: Cost Centre: Full 12 digit cost centre must be provided if the Department / Ward / Team is paying. If no cost centre is provided an invoice will be sent to the participant. In submitting this form I confirm I have approval from my Manager to attend this education session: Manager's Name: Manager's email:
