Title
First Name
Last Name
Address
Postcode
Phone
Email
I would like to receive information via email

I would like to be contacted about opportunities to provide feedback and to participate in ISCHS service planning and decision making

I certify that I am over 18 years of age and I live, work or am an enrolled student at an educational institution in a local government area where the company primarily provides services; or am a carer of an eligible member or a client of the Community Health Service.

I wish to become a member of Inner South Community Health Service Ltd., and I support the objects of the Service.

I agree to comply with the constitution and regulations of the company and undertake to contribute $1 to the company's property if the company is wound up.