Register To Request | Humpty Dumpty Foundation

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Welcome

Our registration and application process has been updated.
Please review all details carefully before submitting.

Please register your details to enable you to request equipment.

Let’s get started...

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Our application process has been optimised to work with the latest browsers.

Please use a modern browser such as:
Firefox, Chrome, Microsoft Edge Chromium, or Safari versions 12 and higher.

Legacy support is provided for Microsoft Edge version 17 and 18.
Please consider updating to Microsoft Edge Chromium.
Unfortunately Microsoft Internet Explorer can not be supported.

Fields with * are required

Title* First Name* Surname*

Email*

Phone (inc area code)* Extension

Your username is your email address.

Please create a memorable password. It must be at least 8 characters long.

Password* Confirm Password *

Password must be at least 8 characters long.

Your Password and Confirm Password do not match.

Please search for hospital and select it if it exists:

Search:

If your hospital does not exist in our database please type it's name here:

Hospital Name*

Department* Your Role*

Number of beds* Number of paediatric beds* Yearly emergency paediatric presentations*

Is there a Special Care Nursery?

Yes No

Is there a Neonatal Intensive Care Unit?

Yes No

Please provide the hospital street location

Street Address*

Address Line 2

Suburb* State* Postcode*

Bio-medical Contact (Mandatory)

Title* First Name* Surname*

Email* Phone (inc area code)* Extension

Service Head Contact (Mandatory)

Title* First Name* Surname*

Email* Phone (inc area code)* Extension

Role or Title*

To help Humpty better support your Hospital, please provide as many contact details below as you can:

Hospital CEO / General Manager

Title First Name Surname

Email Phone (inc area code) Extension

Media / Public Relations Contact

Title First Name Surname

Email Phone (inc area code) Extension

Local Health District

District / Region Name

Local Health District CEO

Title First Name Surname

Email Phone (inc area code) Extension

In providing my details I (the applicant) understand that my email address will be used for Humpty to send updates about my submission.

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Please check that all required* fields are completed before submitting.

Are you a Hospital wanting to apply for medical equipment?