Name (required)

Mailing Address

Phone Numbers

Email (required)

Preferred Contact Method
Home PhoneWork PhoneCell PhoneEmail

What community do you belong to? (i.e. Gillam)

How long have you lived in that community?

Gender:
MaleFemaleOther

Age Category:
Under 1818-2425-3940-5455-7071+

What languages do you speak?
EnglishFrenchOther

Diversity is important to us. Are you a member of either of these groups?
IndigenousVisible minorityPerson with a disability

What is your primary employment status?
Employed Full-TimeEmployed Part-TimeRetiredCaregiverStudentUnemployed

Please describe your work experience? (paid, unpaid or volunteer)

Tell us about why you want to join a LHIG?

Are there any particular health system topics you would like to see
discussed by the LHIG?

Tell us about any groups or team projects you have been a part of?

What is your primary employment status?
NewspaperRadioManitoba.caBrochureWord of mouthNorthernhealthregion.caOther

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