Primary Membership Do you have lived experience of mental illness? Yes (please complete the rest of this form)No (do not complete this form. Complete and submit an Application for Associate Membership instead) Contact details (Your name and at least one contact address or email is required) Your name Title (required) MrMrsMsMissOther (please specify) First Name (required) Surname (required) Your address Street Address (required) Suburb State —Please choose an option—ACTNSWQLDVICTASSANTWA Postcode Postal address (if different) Street Address or PO Box Suburb State —Please choose an option—ACTNSWQLDVICTASSANTWA Postcode Email Address (required) Home Phone Work Phone Mobile Phone Other/Emergency contact Communication preferences What is the best way for us to contact you? EmailPostHome phoneWork PhoneMobile PhoneSMS Do you want to receive newsletters and other information? Yes by emailYes by postNo thank you How should we send information about AGM's and other major events? Home addressPostal addressEmail Demographics Year of birth Do you identify as being: Aboriginal YesNo Torres Strait Islander YesNo Do you speak a language other than English at home? Yes (please specify) No Gender MaleFemaleTransgenderIntersex Other (please specify) Interest and Involvement in Network Activities Self-Advocacy and Consumer Representation Training (SCR) —Please choose an option—I have completed Self-Advocacy CourseI have completed Consumer Representation CourseI want to attend SCR trainingI'm not currently able to attendI have completed a similar course at (please specify) Consumer Representative Program —Please choose an option—I'm interested in becoming a Consumer RepresentativeI'm not currently able to be a Consumer Representative Policy and Projects Program I want to be involved in discussions and projects in these areas (please specify below):I'm not currently able to be involved Network Events —Please choose an option—I want to be involved in planning eventsI'm not currently able to be involved Than you for taking the time to complete and submit this information.