Pūtahi Manawa - PortalPutahi Manawa

Application Form

Prefix *

Name

Please use your own name for individual membership and the name of the best contact person for organisation membership.

First Name *

Last Name *

Email *

Member *

Role *

Select all that apply to you for individual membership and only "Organisation" for organisation membership

Educator

Health Professional

Researcher

Student

Community Worker

Organisation

Other

Institution / Organisation *

If you chose "Other" in the question above, please let us know your institution or organisation here

You may enter self-employed if that applies, or not relevant if you are joining as a private individual for affiliate membership

Job Title *

You may enter not relevant if you are joining as a private individual for affiliate membership. Please enter your job title if you are signing up on behalf of an organisation.

Why is enhancing equity in health outcomes for Māori, for Pacific Peoples and for women important to you? *

What are the areas of interest, work, research, skills and experience that you would bring to Pūtahi Manawa as a member? *

Please list which social media platforms (if any) that you would like to connect on.

Please attach your CV if you are applying for individual membership (Not required for affiliate membership). Please upload your logo if you are applying for membership on behalf of an organisation. *

Code of Conduct *

I have read the Pūtahi Manawa Code of Conduct and confirm that I will abide by it.

Newsletter Opt In

I would like to subscribe to the Pūtahi Manawa Newsletter

Privacy

I acknowledge that the personal information collected here is only used by Pūtahi Manawa staff for the purposes defined at the time of the collection or a use that complies with these purposes.
See our full Privacy Policy

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