Age-Friendly Reference Group Participant Information

Please complete and answer the questions in the form below. We require this information to determine the characteristics and variety necessary when choosing the people who will take part in this group. 

Membership Representatives

Membership will consist of Consumer Representative, Industry Representatives, Councillors and City of Cockburn Representatives.

Please note: Submitting an expression of interest does not guarantee membership.
Print Form

Age-friendly Reference Group Membership Application Form

All fields are required except where indicated
Note: street number and street name are needed for all addresses
The required criteria is

*Please Note: Only one employee may represent that organisation at each meeting. A proxy may represent that person if the representative is unable to attend.
Your Gender
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9 Coleville Crescent,
Spearwood 6163

PO Box 1215, Bibra Lake DC,
Western Australia, 6965

Office opening hours:
8.30am to 4.30pm
Monday to Friday (excluding public holidays)

Language Support

Cockburn Nyungar moort Beeliar boodja-k kaadadjiny. Koora, yeyi, benang baalap nidja boodja-k kaaradjiny.
Ngalak kaadatj dayin boodja, kep wer malayin. Ngalak kaadatj koora koora wer yeyi ngalang birdiya.

City of Cockburn acknowledges the Nyungar people of Beeliar boodja. Long ago, now and in the future they care for country.
We acknowledge a continuing connection to land, waters and culture and pay our respects to the Elders, past, present and emerging.