ACEM Networks: Application to fill casual vacancies

Expression of Interest Form: Community Member

Please complete this form to submit an Expression of Interest for appointment as a Community Member on the Australasian College for Emergency Medicine (ACEM) Equity and Inclusion Committee for the 2025-2027 term of office. Applications that reflect the diversity of the ACEM membership are encouraged. Where applicable, appointments will be made with consideration given to the objective of ensuring this diversity is reflected in the membership of the entity.

Applications close at 9:00am AEST on Monday 29 September 2025.

1. Applicant Details

Please provide your details below.

ACEM ID (if applicable)

Name:*

TtileFirst NameLast Name

Email:*

example@example.com

Address:*

Street Address

Street Address Line 2

CityState / Territory

Postal / Zip Code

Phone number:*

Please indicate your gender identity:*

Are you Aboriginal, Torres Strait Islander or Māori? (please select all boxes that apply):*

Yes, AboriginalYes, Torres Strait IslanderYes, MāoriNo

2. Available Positions

The composition of the Equity and Inclusion Committee includes up to three (3) Community Members with lived experience and/or acknowledged expertise relevant to the matters being considered by the Committee, such as disability, neurodivergence, culturally and/or racially non-dominant, LGBTQIA+ITSB, appointed by the ACEM Board pursuant to the Policy on the Appointment and Remuneration of Community Members (COR498). At least one (1) Community Member must have lived experience.

Please provide an outline below of your lived experience and/or acknowledged expertise relevant to the matters being considered by the Equity and Inclusion Committee:*

3. Supporting Statements

a) Statement of Intent

Please provide a brief statement that describes the contribution that you feel you could make to the ACEM Equity and Inclusion Committee and addresses the requirements of the role and relevant experience (not exceeding 500 words):*

0/500

b) Statement on the ACEM Core Values

The ACEM Core Values of respect, integrity, collaboration, and equity define the organisation’s guiding principles, and underpin the way ACEM works in order to meet its vision and mission of ensuring the highest standards are maintained in the training of emergency physicians, and in the provision of emergency care to the communities of Australia and Aotearoa New Zealand.

Please describe how you demonstrate a commitment to the ACEM Core Values (not exceeding 500 words):*

0/500

4. ACEM Core Values Module

All appointees to ACEM roles and entities are required to have completed the ACEM Core Values module. Please indicate if you have completed the module or confirm your undertaking to complete the module if appointed.

ACEM Core Values module status:*

Yes, I have completed the ACEM Core Values moduleNo, I have not completed the ACEM Core Values module but I undertake to complete if appointed as a Community Member

5. Curriculum Vitae

The Curriculum Vitae provided will be made available to members of the ACEM Board and/or their delegate for consideration of appointment. Please ensure any personal details are omitted, as required.

Please upload a copy of your current Curriculum Vitae:*

Browse Files

6. Conflicts of Interest

ACEM requires all entity members to disclose any conflicts of interest (perceived or actual) in line with the Conflict of Interest Policy (COR139). Please indicate any conflicts of interest to be considered in the context of potential appointment to the ACEM Equity and Inclusion Committee. If there are none, then please leave this field blank.

Conflicts of Interest:

7. Declaration

I declare that the information provided in this application is true and accurate to the best of my knowledge. I confirm that I provide the perspective of non-clinical individuals on emergency medicine care to the Equity and Inclusion Committee being that I am not a College member, not enrolled in an ACEM training program, and not otherwise ineligible for appointment pursuant to College regulations or policies. I also acknowledge that my Curriculum Vitae and Supporting Statements will be made available to members of the ACEM Board and/or their delegate for consideration of appointment.

Signature (please make your mark on screen)*