Majarlin Placement Registration Form

If you have been allocated a placement in the Kimberley (including the Majarlin Work Readiness Program) and you would like to access the services and benefits that Majarlin offer, complete the registration form below.  Once you have lodged your registration form you will receive a welcome email which includes important information.

Personal details

Date of Birth *
Ethnicity *
International *
Rural background * Residency for at least 10 years cumulatively or any 5 years consecutively in an Australian Statistical Geography Standard – Remoteness Areas 2 to 5. Please use the ASGC look-up tool to determine if you are of rural origin.

University details

Please upload a scan/copy of your Student ID Card

If you do not have a WA WWCC we will contact you with further information

Emergency details

Placement details

First day of placement *
Final day of placement *


Do you plan to book accommodation on campus at Notre Dame University Broome? *
  (If Y, complete and submit this form)
Do you have any special needs or disabilities that need to be considered for your placement? *
If Yes, please describe
By ticking this box you agree to arrange and bring your currently valid Police Check, Working With Children’s Check and any other paper work that has been requested of you by your university or host organisation for the initial day of your placement.

Student Placement Health Declaration

Are you aware of any medical condition, physical or otherwise, that may impact upon your placement? This may include but is not limited to: lack of sero-conversion for Hepatitis vaccine, Asthma, heart condition, spinal/back problems, mental health condition, life threatening allergic reactions, a carrier of a blood born disease such as hepatitis, HIV etc.
If Yes, please describe

The information provided in this form will only be used for the administrative or educational purposes of the University, or in accordance with your specific consent. The University will not disclose your personal information to a third party unless required to or permitted by law or where you have consented to the disclosure. Information relating to how the University collects, uses or discloses your personal information and how you may complain about the University’s handling of your personal information is contained in the University’s Privacy Policy.
You have a right to access your personal information that the University holds about you and to seek its correction. If you wish to access your personal information or inquire about the handling of your personal information, please contact the relevant Campus Registrar via email: (for Broome / Fremantle Students), or (for Sydney Students)