The District Nurses
Client Advisory Body - Expression of Interest Registration
Full name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Postcode
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Contact preferences (how would you like to be contacted?)
Email
Post
Phone
Please tick the box that best describes you
I am receiving Aged Care Services from The District Nurses
I am a carer/family member/support person of a current aged care client of The District Nurses
Client's Name:
Client's Postcode
About you
Female
Male
Gender Diverse
Prefer not to say
Prefer to self-describe (specify):
Other
Interpreter required:
Yes
No
Other
Do you need any other support (e.g. information provided in audio format, translated material, or any other support you can think of)?
Do you identify as:
Aboriginal or Torres Strait Islander
Culturally & linguistically diverse
LGBTQIA+
Living in a rural or remote area
Living with dementia
Veteran
Living with disability
Care Leaver (a person who spent time in care as a child under the age of 18)
Young person with caring responsibilities
Prefer not to disclose
thedistrictnurses.org.au
2 Birdwood Avenue Moonah 7009
P (03) 6208 0500 F (03) 6273 3002
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The District Nurses
Please tell us why you are interested in joining our Client Advisory Body, a little bit about yourself and what you hope to contribute.
Please tell us about any aged care topics that are of particular interest to you (please note, this does not mean we will only ask you about these topics):
Please advise of your anticipated availability for meetings
By signing this application form below, you are expressing an interest in being part of The District Nurses' Client Advisory Body membership group:
Full Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Please send this application to Stephanie Page, Client Experience Manager
2 Birdwood Ave, Moonah, TAS 7009 E: spage@thedistrictnurses.org.au
thedistrictnurses.org.au
2 Birdwood Avenue Moonah 7009
P (03) 6208 0500 F (03) 6273 3002
Experts
in care
since
1896
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