Become a Member

Become a member of your Local Health Cluster. Complete the form below to submit your membership application.

1. First Name:* required

Maximum 255 characters

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2. Last Name:* required

Maximum 255 characters

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3. Address

Maximum 255 characters

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4. Postal Address

Maximum 255 characters

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5. Phone:

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6. Mobile:

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7. Email:* required

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8. Name of Local Health Cluster* required

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9. Email for Community Health Connections Use: (Some participants prefer to use a private email, rather than their work or a shared email)* required

Maximum 255 characters

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10. What areas of health are you most interested in?

Maximum 255 characters

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11. Special skills and / or experience?

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12. By applying to become a member of a Local Health Cluster. 1. The applicant warrants that he/she has a genuine interest in health and either resides in or works as a health service provider within the boundaries of the relevant Local Health Cluster. 2. The applicant agrees to be bound by the relevant Local Health Cluster constitution. 3. The applicant agrees to his/hers name being recorded in the register of members of the Local Health Cluster. I accept.* required

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