Community Engagement Advisory Committee (CEAC)
Application Form
If you are interested to join the WRHC Community Engagement Advisory
Committee (CEAC), please read the CEAC Terms of Reference and complete
this Application Form.
Please forward your application to: Community Engagement Advisory
Committee, Western Region Health Centre, 72-78 Paisley Street, Footscray or
Participation@wrhc.com.au. Applications will be reviewed by a selection
panel and all applicants notified of the outcome of their application.
For more information, please contact the WRHC Access & Engagement on
Participation@wrhc.com.au or9680 1116 or speak to a WRHC staff member.
Information provided by you is for the purpose of processing your application
for CEAC Membership. This information will be kept confidential and held
securely by the Centre, and will not be passed on to a third party without your
consent.
Do you need an interpreter?
Yes. Which language:_______________________
If you need an interpreter, please call the Translating and Interpreting Service (TIS National) on
131 450 and ask them to telephone Western Region Health Centre on 9680 1116. Our business
hours are 8.30am-5pm.
Nếu cần thông ngôn viên, xin quý vị gọi cho Dịch Vụ Thông Phiên Dịch (TIS Toàn Quốc) qua số
131 450 và nhờ họ gọi cho Western Region Health Centre qua số 9680 1116. Giờ làm việc của
chúng tôi là 8.30am - 5pm.
،131 450 ‫( على الرقم‬TIS National) ‫ الرجاء االتصال بخدمة الترجمة الخطية والشفهية‬،‫إذا كنتم بحاجة إلى مترجم‬
‫ أوقات عملنا هي‬.9680 1116 ‫ على الرقم‬Western Region Health Centre ‫والطلب منهم االتصال بوكالتكم‬
.8.30am -5pm
若你需要口譯員，請致電131 450聯絡翻譯和口譯服務署（TIS National），要求他們致電 9680 1116
聯絡Western Region Health Centre。我們的工作時間是 8.30am – 5pm。
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Community Engagement Advisory Committee (CEAC)
Application Form
Personal Details
First name/s:
Family name:
Preferred Title:
Ms
Mrs
Mr
Other:
Home address:
Post code:
Home phone number:
Mobile phone number:
Email address:
My preferred contact is by (tick one box or, on a computer, double click on the box to
‘check’ it)
Phone
Email
Mail
How did you find out about this opportunity:
Friend
Colleague
WRHC
Other
Do you prefer to use an interpreter:
Yes
No Which language:
QUESTIONS BELOW ARE OPTIONAL:
Are you:
Aboriginal
Torres Strait Islander
Both Aboriginal & Torres Strait Islander
Neither Aboriginal & Torres Strait Islander
What is your cultural background/ethnicity:
Do you speak any other language(s):
Your age range:
18 – 25
26 – 35
36 – 55
56 - 75
>75
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Interests and Experience
Please  or ‘check’ the responses most relevant to you.
1. What is your connection with Western Region Health Centre (WRHC) and Melbourne’s
West?
I am a current WRHC client / consumer
I am a carer of a client / consumer
I am a past WRHC client / consumer
I am a relative of a client / consumer
I live in the local area
I work in the local area
I volunteer in the local area
Other:
2. Please provide examples of your connections and involvement in Melbourne’s West
3. Please tell us why you are interested in joining this committee and what
experience you will bring:
4. If you have participated on other groups, committees or networks, please tell us
about your experience:
5. What do you hope to gain as a member of this committee? (e.g skills, knowledge)
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Availability
6. CEAC meetings are held in Footscray on the second Wednesday of the month from
5.30 – 7.30pm?
Are you available to attend at this time?
Yes
No
7. New CEAC members are invited to participate in orientation and training sessions.
These are likely to be held between January and March. Please indicate your
availability at the following times:
Saturdays
After 5.30pm on a weekday
during work hours (9-5pm)
Any comments or additional information about your availability:
Referee
As part of the recruitment and selection process, we may wish to find out more about
your involvement Melbourne’s West. Please provide the name and phone number of
someone you are happy for us to speak with. This may be a volunteer coordinator,
community leader, manager or someone else you’ve worked with in the community.
Name:
Phone
number:
Declaration
I have read the Community Engagement Advisory Committee (CEAC) Terms of
Reference, I am over 18 years of age and all statements in this application are true
and correct.
Signature
(type or sign):
Date:
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