Health Networks - Collaborative health care planning for the whole community

How to get involved

Registration / Unsubscription Form

* Compulsory Fields.

Please select the type of submission you would like to make below: * New Member or Update Details or Unsubscribe as a Member
1.	Professional Details
	Title: (Ms / Mr / Mrs / Dr / Prof / Other) *
	Last Name: *
	First Name: *
	Organisation Name: *
	Department:
	Position: *
	Department of Health Employee

2.	Contact Details
	Phone: *
	Fax:
	Mobile:
	E-mail: *
	Address: *
	Suburb: *
	State: *
	Post Code: *
	Comments: (Optional)

3.	Would you like to receive our electronic newsletter, NetNews, which is produced every two months? *
	Yes No
4.	Would you like to receive regular updates on the networks you have expressed an interest in? *
	Yes No

5.	Would you like to nominate to participate in Working Group(s): *
	Yes No I understand that inclusion on this datatabase does not mean that I will automatically be appointed to any working groups. (please tick)

6.	What sector(s) do you represent? (please tick) *
	Allied Health – please specify: Doctor – please specify: Nurse Aboriginal Health Carers Consumer GP Division Non Government Organisations Population Health / Prevention Professionals Policy / Planning Primary Care Team Researchers and Academics Other – please specify:

7.	Please indicate what area(s) in which you may have an interest (please tick) *
	Aboriginal Health Acute Care Aged Care Cancer & Palliative Care Cardiovascular Health Child & Youth Health Digestive Health Endocrine Health Falls Prevention Genomics Infections and Immunology Injury and Trauma Mental Health Musculoskeletal Neurosciences and the Senses Primary Care Renal Health Respiratory Health Women's and Newborns' Other – please specify:



If you have any problems, queries or require assistance completing the Registration / Unsubscription Form please contact us on (08) 9489 2800 or alternatively email healthpolicy@health.wa.gov.au.

How to get involved

Registration / Unsubscription Form

Please select the type of submission you would like to make below: *

1.

Professional Details

2.

Contact Details

3.

Would you like to receive our electronic newsletter, NetNews, which is produced every two months? *

4.

Would you like to receive regular updates on the networks you have expressed an interest in? *

5.

Would you like to nominate to participate in Working Group(s): *

6.

What sector(s) do you represent? (please tick) *

7.

Please indicate what area(s) in which you may have an interest (please tick) *