Membership Application – Individual Step 1 of 4 25% Title(Required)MrMrsMsMxMissFirst Name(Required)Last Name(Required)Street Address(Required)Suburb(Required)State(Required)ACTNSWNTQLDSATASVICWAPostcode(Required)Phone(Required)Email(Required) Photography / video consent(Required)I consent to be photographed or video recorded during my attendance at HCCA events, and for these images to be used in promotional and other relevant materials by HCCA. This question does not affect your application, it is simply for our records. Yes No Donations Joining HCCA is free but we welcome donations. Donations are used to support us in our work to improve the quality and safety of health services and ensure our health system meets the needs of consumers and our communities. If making a donation via EFT please deposit into the following account and include your full name as a reference: Account name: Health Care Consumers’ Association BSB: 112-908 Account no: 410 919 896 Health Care Consumers’ Association is a Deductable Gift Recipient organisation. All donations of $2 or more are tax deductible.I wish to donate to HCCALeave blank if not donating Newsletters Please let us know if you would like to receive our newsletter. Consumer Bites contains updates about HCCA activity, as well as health consumer news and resources. It is issued every second Tuesday and you can view previous issues on our website here: https://www.hcca.org.au/newsletters/ If you're not sure, you can always sign up now and unsubscribe at any time! Each newsletter includes a link at the bottom to manage your subscription, or you can reply to the email.I would like to receive... Consumer Bites (fortnightly) Member profile To help us build a profile of our members we ask that you provide additional details. This is optional but we would appreciate your assistance. This information remains confidential and will be used for internal processes only.How did you find out about HCCA?Year of birthPlease enter a number from 1930 to 2050.Gender Man Woman Non-binary Other gender Prefer not to say Level of education Less than secondary Secondary Tertiary Post-graduate Are you from a multicultural background? Yes No If yes, please share any information you'd like to about your backgroundAre you from an Aboriginal or Torres Strait Islander background? Yes No If yes, please share any information you'd like (eg. nation or people)Areas of interest Medication Safety Complaints Management Health Policy Health Literacy Consumer Handouts Research Health Workforce Digital Health Signage and Wayfinding Health Service Building Design & Construction Other Involvement Commenting on documents and policies Health policy development Attending occasional meetings or seminars Sharing your stories with others Becoming a consumer representative Organisational guidance Other Agreement to Constitution and Code of Conduct I apply for membership of the Health Care Consumers’ Association of the ACT and I agree to support the objectives set out in its Constitution. The Constitution can be viewed at https://www.hcca.org.au/about/governance/constitution/ Agree to Constitution I agree By joining the Health Care Consumers’ Association of the ACT, I agree to comply with the HCCA Code of Conduct for members. The Code of Conduct can be viewed at https://www.hcca.org.au/publication/hcca-code-of-conduct/ Agree to Code of Conduct I agree Please select, I agree to the above fields to proceed.By submitting this form, I agree that all the information in this application is true and correct. I acknowledge that I have agreed to the declaration that I agree to accept and fully support the Aims and Objectives of the Association as set out in HCCA's Constitution.PhoneThis field is for validation purposes and should be left unchanged.
