AccessHC Community Advisory Committee - Application Form

Are you interested in helping us improve health and community services where you work, live or study?

We invite you to apply to our Community Advisory Committee.

To apply, please complete this form and press submit.

Name *

Pronouns

Address

Phone number

Email *

Members of the Community Advisory Committee bring their personal lived experience, local expertise and knowledge of their local community. At the meetings, you will be asked to share your views and reflect on community, rather than individual issues. We encourage members from diverse membership to reflect the local community (across Wurundjeri Woi-Wurrung Country) and consumers who use community and/or health services, their families and carers.

Tell us about yourself. What experience will you bring to the committee, as a consumer, carer or community member?

Why are you interested in joining the AccessHC Community Advisory Committee?

What links do you have to your local community, groups or organisations? For example, community associations, interest groups, recreational or sport groups.

Please share other information you would like to include (e.g. work history; which AccessHC site or service you have used or been involved with; skills you will bring to the committee).

If successful, do you agree to complete the following as a member of the Community Advisory Committee (at no cost to you)? Working with Children Check and Police Check.

Yes No

Demographic information

We encourage you to complete as much of this section as you feel comfortable. This information helps us understand the diversity of the committee and how we can support you to participate.

Gender

Country of birth

Date of birth

Language spoken at home

Do you identify as any of the following:

Aboriginal and Torres Strait Islander LGBTQI+ A person with a disability A carerA person (or carer of someone) with lived/living experience of mental health, addiction, the justice system, social housing or other

Do you need any support to participate in the committee (e.g. access support, translated materials, an interpreter/Auslan interpreter)

Yes No

If yes, please provide some more information.

Do you have any dietary requirements (for catering purposes)?

YesNo

If yes, please provide some more information:

How would you prefer to be contacted?

Phone EmailPostal mail

Please click on the verification below: *

For enquiries, contact Fiona Read on 9810 3042 or email info@accesshc.org.au

Your information will be handled and maintained in line with the AccessHC Privacy and Consent Procedure and relevant privacy legislation.

If you are employed by or represent a health service organisation you are not eligible to apply.