Redevelopment Community Representative Application
Title
First Name
Last Name
Address
Phone
Mobile
Email Address
Preferred Contact Method
Phone
Mobile
Email
Mail
Do you speak any other languages?
Yes
No
If yes, what language is spoken?
Please advise your age range
18-25
26-35
36-45
46-55
56-65
66-75
75+
Why would you like to contribute to the redevelopment of Campbelltown Hospital?
What are your areas of interest/experience/exposure in the following health services
(you are able to select more than one)
Mental Health
Acute Hospital Services
Surgical Services
Paediatrics
Emergency
Aboriginal/Torres Strait Islander
Culturally Diverse Services
Disability Services
Womens Health
Other
Are you
(you are able to select more than one)
Patient
Carer
Volunteer
Worker in Health/NGO Organisation(s)
Family Member/Relative
Other (list below)
Other
Please select the areas you are interested in
Cultural Inclusion
Art (Music, Sculpture etc)
Wayfinding
Landscaping
Interior Design
Front of House Design
Technology
Research/Education
Marketing/Communications
Retail
Access & delivery of Health Services
Transport
Do you have other existing community commitments?
(Rotary, Lions Club, social groups, church groups, Probus)
I would like to receive the Campbelltown Hospital Redevelopment quarterly Newsletter
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