Aboriginal and Torres Strait Islander Health Strategy Development Group: 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) Aboriginal and Torres Strait Islander Health Strategy Development Group 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 Friday 10 April 2026.

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 / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Yes, AboriginalYes, Torres Strait

2. Available Positions

The composition of the Aboriginal and Torres Strait Islander Health Strategy Development Group includes up to four (4) Aboriginal and/or Torres Strait Islander Community representatives, appointed by the ACEM Board pursuant to the Policy on the Appointment and Remuneration of Community Members (COR498).

Please provide an outline below of your lived experience and/or acknowledged expertise relevant to the matters being considered by the Aboriginal and Torres Strait Islander Health Strategy Development Group:**

3. Supporting Statement

Statement of Intent

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

0/500

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

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.

Yes, I have completed the 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:*

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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 Aboriginal and Torres Strait Islander Health Strategy Development Group. 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 Aboriginal and Torres Strait Islander Health Strategy Development Group 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)*