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Rural Strategic Engagement Advisory Group Member and Co-Chair application.

Rural Strategic Engagement Advisory Group Member and Co-Chair application.

Contact Details

Title

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First Name

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Last Name

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Email Address

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Mobile Number

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Address

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Age

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18 - 24 years

25 - 34 years

35 - 44 years

45 - 60 years

60+ years

Prefer not to say

EOI Application

Please select one of the options below:

* required*

I wish to join the group as a community member

I wish to join this group as a clinical/healthcare professional member

Please indicate below. More than one option can be selected:

* required*

I live in a Rural area, as defined by the PHN Rural and Urban/Inner Regional Footprint

I work in a Rural area, as defined by the PHN Rural and Urban/Inner Regional Footprint

I receive services in a Rural area, as defined by the PHN Rural and Urban/Inner Regional Footprint

10.

Profession:

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11.

Please list all groups, agencies, boards, associations and committees of which you have been/or are currently a member, inclusive of the name of each, your position, length of tenure and currency:

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12.

Please outline your areas of interest in primary healthcare:

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13.

Qualifications (inclusive of Degrees, Governance and Board qualifications):

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14.

Why are you interested in joining the Rural Strategic Engagement Advisory Group?:

* required*

15.

Provide an example of how you would advocate/promote the role of the PHN in your local area:

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Co-Chair Application

16.

In addition to my application as a member of the Advisory Group, I would also like to apply as Co-Chair

* required*

YES

If NO please proceed to next section 'Referees'.

17.

If YES, why are you interested in applying for the role of Co-Chair for the Rural Strategic Engagement Advisory Group?

18.

If YES, describe the process and approach you’d undertake to work effectively and collaboratively with the group’s Co-Chair

19.

If YES, with your knowledge and expertise, what are three things you would like to see improve in primary healthcare.

Referees

Please provide details of two referees, one professional and one personal.

Professional Referee:

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Name:

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Organisation/Practice:

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Relationship to you:

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Profession:

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Address:

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Phone:

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Professional Referee email

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Personal Referee:

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Name:

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Organisation/Practice:

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Profession:

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Address:

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Phone:

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Relationship to you:

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33.

Personal Referee email

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Terms and Conditions

For Members: Are you able to prioritise your commitment to attend quarterly meetings in 2024 and 2025? Meetings will be of two hours duration and held online. There may be the requirement for one face-to-face Advisory Group meeting per annum.

For Co-Chairs: Are you able to prioritise the requirement to be available for agenda setting prior to each quarterly meeting? A commitment of one-two hours is required for agenda setting.

By submitting this application, I agree that the facts set forth in it are true and complete. I understand that if I am accepted as a member/Co-Chair of a Strategic Engagement Advisory Group, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

34.

I have read and agree to the Terms of Reference for the Strategic Engagement Advisory Groups

* required*

I understand and accept