National Palliative Care Strategy - Stakeholder Registration

1. Stakeholder Registration

Thank you for your interest in the Update of the National Palliative Care Strategy.

Consultation with a wide range of stakeholders is sought, with opportunities for broad consultation offered through:
 a survey, and
 eight (8) workshops to be held across Australia in March 2010 (dates and locations below).

Please register your details on this form and we will contact you direct to advise:
 when the survey is available for completion, and
 the location and time of the consultation workshops you would like to attend.

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* 1. Please provide your details

Name:

Company:

City/Town/State

Email Address:

Phone Number:

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* 2. If you do not have access to email please provide a postal address.

Address:

Address 2:

City/Town:

State:

Post Code:

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* 3. Please identify your interest

Service provider

Researcher /academic

Consumer / Client / Carer

Health professional

Policy / funder

Advocacy / Support

Other (please specify)

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* 4. Workshops will be held in the following locations during March 2010. I would like to register for the following workshops:

10 March Melbourne

11 March Hobart

12 March Sydney

15 March Canberra

17 March Adelaide

18 March Perth

24 March Brisbane

25 March Darwin