CONSUMER ADVISORY COMMITTEE
Alzheimer's Australia Vic
Consumer Advisory Committee – Nomination form
2014
NOMINATION FORM
Alzheimer's Australia Vic is committed to consulting with people living with dementia about their concerns and the issues that impact on their quality of life, such as the services available to them.
Appointment to the Consumer Advisory Committee is by nomination and a selection process to ensure broad representation. Nomination is open to anyone who meets the criteria of being a current or past client of Alzheimer's Australia Vic, whose contact with the organisation results primarily from their personal rather than professional circumstances.
The CEO of Alzheimer’s Australia Vic will confirm appointment of nominees to the Consumer Advisory Committee. Appointment is for a period of 2 years, with the opportunity for reapplication.
¨ I wish to nominate for Alzheimer's Australia Vic’s Consumer Advisory Committee
¨ I have read and understood the Terms of Reference for the Consumer Advisory Committee.
Signed……………………………………………………………. Date………………………………………
Please provide the following details and return to:
Consumer Engagement Officer
Alzheimer's Australia Vic
Locked Bag 3001
Hawthorn 3122
Fax: 9815 7801
Email:
Name:………………………………………………………………………………………………………………….
Address:……………………………………………………………………………………………………………….
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Phone No: H.……………………………….………….. W………………………………………………….
Mobile:……………………………………………….. Email…………………………………………………..
Emergency Contact:
Name:…………………………………………….. Relationship:…………………………………………..
Address:…………………………………………. Phone ……………………………………………………
Please indicate your situation:
Alzheimer's Australia Vic
Consumer Advisory Committee – Nomination form
2014
¨ Currently caring for a person with dementia at home
¨ Currently caring for a person with dementia in residential care
¨ Formerly cared for a person with dementia
¨ Person with diagnosis of dementia
Please turn over
Alzheimer's Australia Vic
Consumer Advisory Committee – Nomination form
2014
Your relationship to the person with dementia:……………………………………………………………………..
Please provide details of the living and care arrangements of the person with dementia (e.g. does the person with dementia live at home or in a residential facility; have you accessed a care package)? ….……………………………………………………………………………………………………………………..
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When was dementia diagnosed?………………………………………………………………………
What condition was diagnosed? (e.g. Alzheimer’s disease, Frontal lobe dementia)……………………………...……….
Are there any other details that might be helpful for us to know about diagnosis, care arrangements etc: ……………………….…………………………………………………………………………………………………….
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Are you in paid employment? ¨ Yes ¨ No
Occupation:……………………………………………………………………………………………..
Do you speak a language other than English at home? ¨ Yes ¨ No
Language:……………………………………………………………………………………………..…
What services provided by Alzheimer's Australia Vic have you used?
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Do you have any other contact with other people with dementia/family members caring for a person with dementia? How do you have this contact (e.g. support group)?
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Are you involved with any other community groups or organisations?
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Is there any other information about yourself that you think would be useful for us to know?
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Introductory/Professional biography
Sometimes people on the committee become involved with other activities where it is useful to introduce people, and recognise their professional accomplishments, in addition to their commitment to caring for a person with dementia. This activity could, for example, include a speech, an important meeting, or media interview. You can include information such as employment (or previous employment), education and training, volunteer roles, awards, particular interests in relation to dementia, and anything else you feel is noteworthy.
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Alzheimer's Australia Vic will not disclose any of your personal details to anyone without your consent
Alzheimer's Australia Vic
Consumer Advisory Committee – Nomination form
2014
Thank you for taking the time to nominate.
You will be informed about the outcome of you nomination by the Consumer Engagement Officer.
Alzheimer's Australia Vic
Consumer Advisory Committee – Nomination form
2014