Patient-Centred Health Care Network

Membership Form

           Here is my contact information

Name
Title
Organisation
Work Phone
FAX
Email

          Here is the description which best fits my current situation

         

I would like to:  

Become a member of the Patient-Centred Health Care Network
Participate in a public engagement strategy around the model
Convene a regional initiative/forum in my area on the model

Please outline your qualifications and skills, and what you can bring to the Network:



My skills are in

Health Sector expertise
Business Development
Marketing

Media

Community Engagement

Fundraising

 

    Membership Fee 

$55





I will send my cheque/money order to   Social Enterprise Partnerships,
2 Elm St, North Melbourne 3051
OR  
I will make a payment using the secure online credit card payment facility
(Visa/Bankcard/Mastercard accepted) CLICK on this link NOW to use our secure payment system. Then close the window and submit this form. 

I understand that a tax invoice/receipt will be forwarded to me on receipt of payment. (If you require an invoice prior to making a payment, please indicate.)

         

Back to PATIENT-CENTRED HEALTH CARE NETWORK
         
          PRIVACY STATEMENT:  Your details will be held in the strictest confidence and
          will not be passed onto a third party.

          Social Enterprise Partnerships Ltd
          ABN 47108742098
          2 Elm Street
          North Melbourne
          Phone (03) 9326 4481
          Fax (03) 9326 8030