Join our Community Advisory Network

First name

Last name

Email

Gender

Prefer to self-describe (optional)

Postcode

Phone

Birthday

Do you identify as Aboriginal or Torres Strait Islander?

Do you speak another language other than English at home?

If yes, which language(s) (optional)

Do you identify as LGBTQI+?

Are you or the person you care for living with a disability?

(i.e. sensory impairment, mobility impairment, learning disability, or other)

If yes, please tell us about the disability(s) (optional)

Have you had cancer?

What cancer were you diagnosed with? (optional)

Have you cared for someone with cancer?

What cancer was the person you care for diagnosed with? (optional)

How would you like to be involved with Cancer Council? (optional)

Tick all that apply.

Have you done any work (paid or volunteer) with any other health agencies / not for profits / support organisations? (optional)

Which Organisation? (optional)

If yes, please provide details (optional)

Do you have experience in any of the following (check all that apply) (optional)

Please provide details (optional)

Have you used Cancer Council’s Support Services before? (optional)

Yes
No

What services have you used? (optional)

Cancer Council 13 11 20 service
Cancer Council nurse counselling
Cancer Council legal support
Cancer Council financial counselling
Other

If other, please provide details (optional)

Are you currently involved with Cancer Council in any other way? (e.g., peer support groups, fundraising, attended workshops etc.) (optional)

If yes, please provide details (optional)

Agree to complete evaluation following completion of the engagement

Privacy Policy

By completing this form, you have provided Cancer Council Victoria (CCV) with your personal, sensitive and health information. We may also collect further personal information about you through our ongoing communication.

CCV’s Privacy Policy and Collection Statement contains general information about how we will handle and hold your personal information, and how you can contact us to seek to access or correct your personal information or make a complaint.

In addition to the uses and disclosures described in our Privacy Policy and Collection Statement, we will use and disclose your personal information to send you our regular community newsletter and to invite you to engage with us on latest opportunities.

By submitting this form, I agree to Cancer Council Victoria collecting and holding my personal, sensitive and health information in accordance with its Privacy Policy and Collection Statement and using such information to contact you about your cancer experiences and some of our activities.

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