To express your interest in joining the Consumer Representative register, please fill in the form below and we will contact you for further information.

Do you have experience at one or more of Eastern Health’s services as a patient, carer, support person, family member or friend?(Required)

Why are you interested in getting involved as a consumer representative at Eastern Health?(Required)

How did you find out about the Eastern Health Consumer Representation Program?(Required)

If other,(Required)

Tell us about you - Work background/What keeps you occupied during the day?

Are you interested in a specific opportunity listed on our website? If so, please tell us which ones you would like to be considered for.

By what name do you prefer to be known?(Required)

Untitled

What gender do you identify with?

If other,

Pronouns

Country of Birth

Where do you currently live in Victoria (Postcode/Suburb)(Required)

What year were you born in?

I am of Aboriginal and/or Torres Strait Islander descent

Do you have any accessibility or support needs?

Do you identify as a carer or support person of a person with disabilities

Do you have a preferred method of receiving correspondence?

What languages are you fluent in?

What is your availability like?

Email(Required)

Phone(Required)