97mm
99mm
99mm
99mm
99mm
97mm
Self Management Course Registration Form
The course is offered at four Community Health Centres.
Please complete the following details and return to the
centre organising your course or fax to 5260 3780.
For phone enquiries contact Barwon Health on
Ph 5260 3778.
Name
Address
Date of Birth
Male / Female
Main language spoken at home
Please list your long-term medical conditions:
Will a support person be attending the course
with you? Y / N
Support person’s name
Your doctor’s name
Your doctor’s phone
Where did you hear about this course?
I agree to be registered for a Self Management Course:
Arthritis
Better Health
Signature
Date