Title of form:
Community Engagement Committee Application

First name 

Surname

Date of birth

Phone number

Address 

Email


Tell us about yourself, including your cultural background and/or lived 
experience as a consumer or carer (150 words or less)





What do you hope to address or achieve by joining our Community 
Engagement Committee? (150 words or less)




Which services at Merri Health do you or your family use? (your information 
will be kept confidential, we ask this question for purposes of seeking fair 
representation)

11 Glenlyon Road, Brunswick VIC 3056
Tel. (03) 9387 6711   Fax. (03) 9387 5417
www.merrihealth.org.au
ABN 24550946840


 
Please note: Family of current Boards members are not eligible for this position. 

Return the completed form by email to Communications@merrihealth.org.au or dropping it off to one of our sites. 
Applications close Friday, 23 March.