Barang JDM Community Panel Expression of Interest Form Question Title * 1. Contact Details Name Company Address City/Town State/Province ZIP/Postal Code Email Address Phone Number OK Question Title * 2. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older OK Question Title * 3. What is your gender? Female Male OK Question Title * 4. Why have you applied to be a Community Panel Member OK Question Title * 5. Describe your connection to the Central Coast Aboriginal Community OK Question Title * 6. Please outline your skills and experiences for the program areas below that you wish to be a panel member of Local Cultural knowledge Jobs & Economy Health & Wellbeing Children & Schools Familes & Community services Housing Other OK Question Title * 7. In reading the code of ethics do you consider that you have any interest that would conflict with the required role of impartiality as a community panel member? Yes No If Yes, please explain OK Question Title * 8. Select the times of the week you would be available to participate in a 2 to 4 hour panel meeting or induction session Weekdays AM Weekdays PM Weekdays after 5pm Saturday Sunday Other (please specify) OK DONE