Bethlehem Consumer Register

Your privacy - how we use this data:

By completing and submitting this registration you are giving your consent for the information you have provided in this application to be included on the register.

Your registration information will not be connected to a patient record.

On receipt of your registration application we will be in contact with you to discuss how you can become involved in helping us to improve the services we provide.

I agree to the privacy terms and how my data will be used. *

First name *

Last name *

Phone *

Email address *

Address *

Street address *

City *

State *

Postcode *

Preferred contact method: *

EmailPhoneOther

Please specify: *

About you

Age group *

Country of birth *

Do you identify as an Indigenous Australian or Torres Strait Islander? *

YesNo

Language(s) spoken at home: *

Do you have a connection with Calvary Health Care Bethlehem?

YesNo

If other, please specify: *

Lived experience

Sometimes we need opinions and advice from people with knowledge and experience in particular areas developed as a result of their lived experience.

Let us know the area/s where you have knowledge and experience to help us improve our services.

Please tick all that apply, or leave blank if not applicable.

"I would be comfortable representing the views of a person...":

Diagnosed with a Progressive Neurological Condition (e.g. Motor Neuron Disease, Huntington’s Disease)Diagnosed with a life limiting illnessCaring for someone diagnosed with a life limiting illnessWho is a carer/family member of a past patientWith special needs and/or their carerOf Aboriginal or Torres Strait Islander origin with a non-English backgroundWith experience of mental health servicesWho is a registered client of disability servicesOther

Please describe: *

Training and experience

Sometimes we need opinions and advice from people with knowledge and experience in particular areas developed as a result of their lived experience.

Please tick all that apply, or leave blank if not applicable.

Please provide further detail: *

Your interests

Tell us how you would like to be involved as a consumer representative.

Please tick all that apply, or leave blank if not applicable.

I am interested in:

being on a committeebeing on a project working group and attending project meetingsbeing involved in researchbeing involved in focus groups/discussion groups on a particular issueproviding input via emailproviding feedback on patient/consumer information materials (eg brochures, flyers, internet information)participating in interviews (telephone or face-to-face)completing surveys (telephone, paper-based or online)Other

How would you like to be involved? *

To learn more about how we safeguard your information, please review our Privacy Policy here.