Name: Jean Hailes
Price range: $

Thank you for your interest in becoming one of our valued People Bank members.

We want you to have a say on things that are important and relevant to you when it comes to your health. To do this, please complete and submit the following registration form.

Answers to questions marked with an asterisk (*) are required.

Your first name*

Do you identify as*

Your email address*

Your phone number

Your postcode*

In what location do you live?*

In which year were you born?*

In which country were you born?*

What language do you mainly speak at home?*

Other language(s) spoken at home

Are you of Aboriginal and / or Torres Strait Islander origin?*

Do you have a disability (physical, mental, sensory or other types of disability)?*

Do you have, or have you had, a transgender identity, experience or history?*

What is your work status?*

What is the highest level of education you have completed?*

Where did you hear about Jean Hailes People Bank?*

Other

I agree that Jean Hailes will occasionally send me opportunities where consumer participation is sought. I understand that I can opt out from receiving communications related to PeopleBank at any time.*

I understand that my details and personal information will be dealt with in accordance with the Jean Hailes Privacy Policy.*

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