First name *
Last name *
Email address *
Phone *
Postal address *
Your primary place of employment *
Please select your age range 18 - 25 years 26 - 35 years 36 - 50 years 51 - 65 years 65 years +
Do you live, work and/or study in Latrobe Valley Live in Latrobe Valley Work in Latrobe Valley Study in Latrobe Valley None of the above
Please provide details (name and purpose) of any Latrobe Valley community groups/ clubs/ networks that you are involved with
Which Latrobe Valley towns do you and the groups/ clubs/ networks that you represent connect with? Boolarra Churchill Glengarry Moe Morwell Toongabbie Traralgon Traralgon South Tyers Yallourn North Yinnar Other (Rural Townships) All of the above
Which communities do you and the groups/ clubs/ networks that you represent connect with? Children 0- 12 years Youth 13 - 17 years Young adults 18 - 25 years Adults People over 65 years Aboriginal or Torres Strait Islanders Multicultural People with a disability LGBTI Unemployed Women's groups Men's groups Young Mums
Please select any of the following backgrounds, skills or areas of interest that are relevant to you Innovation and entrepreneurship Community development Communications and engagement Health promotion Healthy environments Frequent health service user Disability Mental health Child health School and preschool education Tertiary and vocational education Leisure, sport and recreation
If you are involved with or represent any local business, industry or employer groups please select what is most relevant to you from the list below Small business Medium business Large business Local chamber of commerce Local business network Electricity, gas, water and waste Transport, postal and warehousing Information, media and communication Accommodation and food services Financial and insurance Rental, hiring and real estate Professional and technical services Administrative and support services Arts, sport and recreation Agricultural, forestry and fishing Health, care or social assistance Manufacturing Public service and safety Retail and wholesale trade Education and training Construction Other
If you are involved with or represent a local education or training organisation please select what is most relevant to you from the list below Early years settingss Primary schools Secondary schools Vocational Tertiary Public Private
If you are involved with or represent a local Community Service Organisation, please briefly describe your role and the contribution that your organisation can make to the Latrobe Health Assembly
Why are you interested in being a member of the Latrobe Health Assembly? *
What can you contribute to the Latrobe Health Assembly? *
