Consumer and Quality Care Advisory Body Expression of Interest Form

First name

Last name

Address

Phone

Format: 0000000000.

Email

Please select which Advisory Body you would like to express your interest to join:

Please select which of the following best describes you:

As you are a family member or representative of someone who receives Uniting care services, please provide the following details:

Name of the person receiving Uniting care services:

Type of services they receive:

Address or facility name that the person receives care services at:

Address or facility name that you receive care services at:

To help us understand the diversity of the participants in the Consumer Advisory Body, we would like to know if you identify with any of the following, noting that it is not mandatory to provide this information.

Choose what applies:

Are there any supports that you would need to allow you to participate in the Consumer Advisory Body e.g. translating service?

Please specify supports you need

Date of birth

What interests you about being part of the Consumer Advisory Body or Quality Care Advisory Body for Uniting?

In participating in Uniting's Advisory Body, are there any specific topics you would like to discuss?

By submitting this, I agree to be contacted about Uniting services that may be of interest to me and I have read the privacy policy. I can unsubscribe at any time at ask@uniting.org

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Hour MinutesAM/PM Option

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Marketing Channel

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