Apply to become a member

First name *

Last name *

Email address *

Phone *

Postal address *

Your primary place of employment *

Please select your age range18 - 25 years26 - 35 years36 - 50 years51 - 65 years65 years +

Do you live, work and/or study in Latrobe ValleyLive in Latrobe ValleyWork in Latrobe ValleyStudy in Latrobe ValleyNone 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?BoolarraChurchillGlengarryMoeMorwellToongabbieTraralgonTraralgon SouthTyersYallourn NorthYinnarOther (Rural Townships)All of the above

Which communities do you and the groups/ clubs/ networks that you represent connect with?Children 0- 12 yearsYouth 13 - 17 yearsYoung adults 18 - 25 yearsAdultsPeople over 65 yearsAboriginal or Torres Strait IslandersMulticulturalPeople with a disabilityLGBTIUnemployedWomen's groupsMen's groupsYoung Mums

Please select any of the following backgrounds, skills or areas of interest that are relevant to youInnovation and entrepreneurshipCommunity developmentCommunications and engagementHealth promotionHealthy environmentsFrequent health service userDisabilityMental healthChild healthSchool and preschool educationTertiary and vocational educationLeisure, 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 belowSmall businessMedium businessLarge businessLocal chamber of commerceLocal business networkElectricity, gas, water and wasteTransport, postal and warehousingInformation, media and communicationAccommodation and food servicesFinancial and insuranceRental, hiring and real estateProfessional and technical servicesAdministrative and support servicesArts, sport and recreationAgricultural, forestry and fishingHealth, care or social assistanceManufacturingPublic service and safetyRetail and wholesale tradeEducation and trainingConstructionOther

If you are involved with or represent a local education or training organisation please select what is most relevant to you from the list belowEarly years settingssPrimary schoolsSecondary schoolsVocationalTertiaryPublicPrivate

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? *