Local Health Advisory Committee (LHAC) Membership Application

Personal Details

Name *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Phone Number

Email *

Gender *

FemaleMaleOther

Date of Birth *

Committee Interest

For your review:

Local Health Advisory Committee (LHAC) Terms of Reference

I have read and agree to abide by: *

LHAC Terms of ReferenceLocal Health Advisory Committee Confidentiality AgreementThe NSW Health Code of Conduct

I consent to a National Criminal Record Check (this is a requirement to join the LHAC) *

YesNo

I wish to apply for membership to the Local Health Advisory Committee in (please specifiy location)

I identify as being (tick any/all that apply):

AboriginalDisabledReligious MinorityEthnic MinorityNon English speaking backgroundLGBTIOtherNone of the above

Please Specify

I am interested in / able to represent the community wih the following health interests (tick any / all that apply):

Being HealthyHealth Coaching and weight managementDisabilitiesAgeing / FrailCarerMental IllnessDrugs & AlcoholChronic Disease (for example Diabetes, Heart disease, respiratory / pulminory disease)OtherNone of the above

Please Specify

I am interested in / able to represent the community with the following backgrounds (tick any/all that apply):

Sole ParentYoung FamilyPoor Internet accessRemote / isolatedFamily issuesLimited transportLow incomeRuralLow literacyHomelessUnemployedUrbanYouthStudentAdultVeteranOtherNone of the above

Please Specify

I am interested in finding out more / being involved in (tick any/all that apply):

WellnessResearch / DataInnovationTelehealthPatient SafetyImproving Access to Health CareRepresenting Consumers on MLHD CommitteesPlanning & development of FacilititesRaising the profile of health careersPromotion better healthOtherNone of the above

Please Specify

Have you worked in the Health Care Industry? *

YesNo

Please provide a brief outline of your experience in the Health Care Industry:

What do you hope to achieve (your goals / key priority areas) by being involved in the LHAC:

Describe the experience / skills you have that would benefit / contribute to the LHAC:

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