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NF Community Advisory Panel Form

First Name *

Surname *

Email *

Phone Number *

Address *

Suburb *

State *

Postcode *

Country

Gender *

Date of Birth *

Which condition do you/your family member(s) have? (Select from dropdown than tick all boxes that apply.)

Myself

My child

My spouse/partner

Other family member(s)

Friend

Please provide details as to why you are interested in becoming a member of the Panel? (limit 2000 characters) *

What skills, qualifications, experience, and contributions do you feel make you a suitable candidate for the Panel? (limit 2000 characters) *

What other community activities are you involved with which may impact on or conflict with your Panel responsibilities? (limit 2000 characters) *

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