Nicotine Addiction, Smoking & Vaping Cessation
 Registration Form

Complete the details on both pages to register for the 3-day online Nicotine Addiction, Smoking & Vaping course. If you have any questions, please contact lifestylemedicine@avondale.edu.au.  

Click 'save' at the bottom of the form to return to your registration form at a later time.

If you already have an account, Sign In here

Course

Please select ONE course from the 2 options listed below below:
2024 - November Course
2025 - March Course

You do not need to do a search for the course name, code or location.


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Personal Details

Please complete all fields below

Title
Entity Data - Profile - Title
First Name
Entity Data - Profile - First Name
Surname
Entity Data - Profile - Surname
Date of Birth
Entity Data - Profile - Birth Date
Mobile Number
Entity Data - Contact - Home - Mobile Number
Email Address
Entity Data - Contact - Home - E-mail Address
Current Position / Job Title
Basic - Text
Business / Organisation Name
Basic - Text
Department Name (if applicable)
Basic - Text
[Home] Address -
Entity Data - Address

Entity Data - Address - Lookup
[Home] Address - Street Address 1
Entity Data - Address - Street Address 1
[Home] Address - Street Address 2
Entity Data - Address - Street Address 2
Address - NOTE: If your company is paying for the course, please use the company's address.


Unit/Flat Number (if applicable)
Entity Data - Address - Unit/Flat Number
Street/Lot number
Entity Data - Address - Street/Lot number
Street Name
Entity Data - Address - Street Name
Suburb
Entity Data - Address - Suburb
[Home] Address - Overseas State/Province
Entity Data - Address - Overseas State/Province
State
Entity Data - Address - State
Post Code
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Country
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I agree to receive the following course information from Avondale University?
Basic - Checkboxes
Digital Signature
Basic - Digital Signature
Date Signed
Basic - Date