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* 1. Contact Details

ABOUT YOU:

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* 2. Gender:

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* 3. Age:

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* 4. Nationality: Do you identify as:

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* 5. Do you identify from a culturally and/or linguistically diverse background (CALD)

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* 6. Is English your first language?

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* 7. If no, language spoken at home?

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* 8. Do you have a current Working with Children Check (blue card)?

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* 9. Do you have a current Disability Worker Screen Check (yellow card)?

CONSUMER REPRESENTATION:

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* 10. Please outline why you would like to join our organisation as a Consumer Representative:

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* 11. How would you like to be involved?  What are your areas of interest?

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* 12. Do you have any previous experiences as a Consumer Advisor/Representative?

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* 13. If yes, please provide more information?

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* 14. Which applies to your experience:

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* 15. Have you undertaken any previous consumer training?

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* 16. If yes, please tell us what you have done and where it was completed:

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* 17. Please indicate availability below:

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* 18. Are you currently involved with any consumer organisations and/or acted or currently act as a consumer representative on a Committee or Board?

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* 19. If yes, please name the organisation, describe your role and include recent activities that you have carried out.

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* 20. Are you a member of any social, community or charitable organisations or networks? If so, please provide additional information below:

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* 21. What qualities and life skills do you feel you would contribute as a consumer representative with our organisation?

Our hospital values are - Friendliness, Diligence, Courage, Wisdom and Compassion.  Please outline briefly how you would contibute to each of these:

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* 22. Friendliness:

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* 23. Diligence:

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* 24. Courage:

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* 25. Wisdom:

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* 26. Compassion:

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