Membership Application Form – Individuals - Indigenous Allied Health Australia

"*" indicates required fields

MemberID

Are you an Australian citizen?*

Yes

IAHA membership is only for Australian citizens. If you would like updates on IAHA, we encourage you to scroll down and sign up for our newsletter.

Are you*

IAHA membership is only for Aboriginal and Torres Strait Islander people. You are eligible to become a Friend of IAHA. Please complete this application to become a Friend of IAHA

Personal Details

Title*

What is your preferred title?*

Given Name(s)*

Family Name*

Please list any other names you are known by or have previously been known by

Date of Birth*

Day

Month

Year

Place of Birth*

Gender*

Please advise your preferred gender*

Preferred Mailing Address

Address location*

Address*

Street Address Address Line 2 Suburb Post Code

State/Territory*

Do you wish to provide an alternate mailing address?

Yes

Address location*

Address*

Street Address Address Line 2 Suburb State/Territory Post Code

Contact Details

Mobile Phone*

Work Phone

Home Phone

Facsimile

Other

Email Address 1 (preferred personal email)*

Enter Email Confirm Email

Do you wish to provide an alternate email address?*

Yes

Email Address 2

Enter Email Confirm Email

Social Media

Please list any social media links or usernames you would like to share with IAHA (ie - Facebook, Twitter, Instagram, LinkedIn, etc).

Preferred Method of Contact*

Choose how you prefer to be contacted. You may choose multiple methods of contact. Be sure if you choose a method such as work or home phone that you have provided that number above.

Mobile Phone

Work Phone

Home Phone

Other

Contact Method

If you have chosen 'other' please provide details about how you prefer to be contacted

Qualifications

Please choose which best describes you:*

I do not currently hold and am not studying formal qualifications.

I currently hold a formal qualification

I am studying a formal qualification

Please provide more information as to why you wish to join IAHA.*

i.e. Community member? Family member of a current IAHA Member? Do you have allied health or health interests? Do you require IAHA support? Do you have an interest in IAHA or have you assisted IAHA in the past? Are you planning to study, if so, when, where and what?

Please outline all of your qualifications that you hold or are working towards:

Please upload current proof of enrolment*

Max. file size: 20 MB.

Please upload your proof of Graduation: (transcript, certificate, professional association membership, actual qualification certificate)*

Max. file size: 20 MB.

Qualification Title*

Please state the exact title
i.e. Bachelor of Physiotherapy, Masters of Social Work

Profession*

What is or what will your Profession be once graduated?
ie; Physiotherapist, Occupational Therapist

Issuing Institution*

(e.g. The University of Queensland)

Have you graduated from this course?

Yes

Year Commenced

(yyyy - e.g. 1995)

Current Year of Study

(e.g. 3rd Year)

Date Graduated (or expected date)

Month*

Year*

(yyyy - e.g. 2015)

Do you have accreditation?

Yes

Who are you accredited with?

Do you have any further qualifications to add?

Yes

Qualification Title*

Please state the exact title
i.e. Bachelor of Physiotherapy, Masters of Social Work

Profession*

What is or what will your Profession be once graduated?
ie; Physiotherapist, Occupational Therapist

Issuing Institution*

(e.g. The University of Queensland)

Have you graduated from this course?

Yes

Year Commenced

(yyyy - e.g. 1995)

Current Year of Study

(e.g. 3rd Year)

Date Graduated (or expected date)

Month*

Year*

(yyyy - e.g. 2015)

Do you have accreditation?

Yes

Who are you accredited with?

Do you have any more qualifications to add?

Yes

Qualification Title*

Please state the exact title
i.e. Bachelor of Physiotherapy, Masters of Social Work

Profession*

What is or will your Profession be once graduated?
(ie; Physiotherapist, Occupational Therapist)

Issuing Institution*

(e.g. The University of Queensland)

Have you graduated from this course?

Yes

Year Commenced

(yyyy - e.g. 1995)

Current Year of Study

(e.g. 3rd Year)

Date Graduated (or expected date)

Month

Year*

(yyyy - e.g. 2015)

Do you have accreditation?

Yes

Who are you accredited with?

Would you like to add another qualification?

Yes

Qualification Title*

Please state the exact title
i.e. Bachelor of Physiotherapy, Masters of Social Work

Profession*

What is or what will your Profession be once graduated?
ie; Physiotherapist, Occupational Therapist

Issuing Institution*

(e.g. The University of Queensland)

Have you graduated from this course?

Yes

Year Commenced

(yyyy - e.g. 1995)

Current Year of Study

(e.g. 3rd Year)

Date Graduated (or expected date)

Month*

Year*

(yyyy - e.g. 2015)

Do you have accreditation?

Yes

Who are you accredited with?

Mentoring

Are you interested in having a mentor?

Yes

Thank you. We will contact you after your application has been processed.

Are you interested in being a mentor to other IAHA members?

Yes

Thank you. We will contact you after your application has been processed.

Employment

Do you currently work?*

Yes

Current place of work

Position held

Past places of employment

Please list relevant past employment information

Community involvement

Please list relevant community involvement

Do you currently work in Aboriginal and/or Torres Strait Islander health?

Yes

Please provide details

Have you previously worked in Aboriginal and/or Torres Strait Islander health?

Yes

Please provide details

Representing IAHA

Would you like to represent IAHA in the future?

Yes

Which area(s) would you like to represent IAHA?

Tick all that apply

Board of Directors

Committees

Policy

Career Expos/Community Visits

Student Representative Committee

Other

Please specify

Accessibility

IAHA tailor and deliver services and experiences that are safe, inclusive and accessible to our members. If you have any information about yourself on how we can best support you, please provide us with what you feel comfortable in sharing. Any information that is shared is kept private and confidential.

Do you have any access or disability related requirements you would like IAHA to be aware of? (eg: allergies, any impairments or health concerns)*

Yes

Please tell us how we may be able to assist you.*

Declaration

I hereby declare:

I am of Aboriginal and/or Torres Strait Islander descent;*

Yes

I am a descendent of:*

Please tell us your nation/s, your family/s names, your kinship connection.

I identify as an Aboriginal and/or Torres Strait Islander person; and*

Yes

I am accepted as such by the community in which I live or have lived*

Yes

I am accepted by:*

Please enter the name of the community you are accepted by. Tell us your nation/s, your family names, your kinship connection.

Family & Cultural Identity*

Tell us about your family and your cultural identity (max 1500 characters). Tell us your nation/s, your family names, your kinship connection.

Documentation

In order to determine the membership category and type you are eligible for, applicants are required to provide additional information in relation to their declaration. It is our preference that you submit documentation with this application using the File Upload buttons below where possible. If further information is required, you will be contacted to provide such information.

Examples of documentation are listed below:
• Aboriginality confirmation
• If you can prove that a parent is of Aboriginal or Torres Strait Islander descent
• Reference letter/s from Aboriginal or Torres Strait Islander organisations (from your country) on your family and heritage
• Family genealogy

Please note: Statutory Declarations will not be accepted unless they are signed and stamped by an Aboriginal Organisation who can confirm Aboriginal identity

Do you have documentation you can upload now?*

Yes

Please explain why you are unable to upload documents with your application (eg – I am waiting for my documentation to arrive).*

Please note: You can still become an IAHA member if you do not upload documentation. However, your membership category will be Associate member until further information or documentation is received.

Documentation 1*

Max. file size: 10 MB.

Do you have any additional documentation you would like to upload?

Yes

Documentation 2

Max. file size: 10 MB.

Disclaimer

Please tick each box if you agree*

I hereby declare that the information provided in this application form is true and accurate to the best of my knowledge; and

I hereby declare that I have read and will abide by the IAHA constitution

I agree to the use of my personal information for the purposes of IAHA, its secretariat and board, communicating on IAHA matters

As a member of Indigenous Allied Health Australia Ltd I agree to contribute the guarantee amount below to the property of that company if it is wound up

Note: Subject to the Corporations Act 2001 (Cth), where the company is wound up, a present or past member is liable to contribute up to the guarantee amount to the company’s property: (i) to pay the company’s debts and liabilities and the costs, charges and expenses of the winding up; and (ii) to adjust the rights of contributories among themselves. Subject to the Corporations Act 2001 (Cth), a past member will not need to contribute: (a) in respect of a debt or liability of the company contracted after the person ceased to be a member; (b) if he, she or it was not a member at any time during the year ending on the day of the commencement of the winding up; and (c) unless it appears to the court that the present members are unable to satisfy the contributions that they are liable to make.

$ 10.00 (Please do not pay this amount, it is NOT a Membership fee.)

Full Name*

Electronic Signature

Date*

Day

Month

Year

Phone

This field is for validation purposes and should be left unchanged.

Personal Details

Preferred Mailing Address

Contact Details

Qualifications

Please outline all of your qualifications that you hold or are working towards:

Mentoring

Employment

Representing IAHA

Accessibility

Declaration

Documentation

Disclaimer

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