MyImpactPage - Locala Health & Wellbeing

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Account

Username

Required

	Username must not start with space
	Username must not end with space
	Username must not have two or more spaces in a row

Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Confirm Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Name Fields

Salutation
Legal First Name
First Name Required
Middle Name
Last Name Required
Suffix
Pronouns

Address

Address line 1 Required
Address line 2
City Required
Country Required
State / Province Required
Zip / Postal Code Required

Email Addresses

Email Address Required
Secondary Email Address

Phone Numbers

Required Please enter at least one phone number

Home Phone
Work Phone
Work Extension
Cell Phone
Phone Preference

Text Messaging

I want to receive text messages on my cell phone.
Cell Phone Number

Online Presence

X Username @
Linkedin Profile URL
Instagram Username

Misc Fields

Date of Birth mm/dd/yyyyRequired
Region

Monitoring Information

Locala Health & Wellbeing recognises and actively promotes the benefits of a diverse workforce and is committed to treating all volunteers with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

Do you currently identify as

Required

Please describe your ethnic origin

Required

Do you consider yourself to be

Required

Health / Disability Information

The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustment to where you volunteer, and your volunteering arrangements, and at informal interview.

Do you have a health problem or disability that limits your day to day activity?

Required

If you selected 'yes', please select from this list of options

How would you like to be involved?

Receive regular updates and information

Join discussion and focus groups

Join our Readers Panel to review patient literature

Consider standing for election to the Members’ Council

Become a Locala volunteer

Take part in service improvement projects

How are you connected with Locala?

Patient

Carer of a patient

Previously worked for Locala

Student

Volunteer

Not Applicable

How did you hear about Locala?

At a community event

Locala website

Through a friend/family member

Through a Locala colleague

School/college

Other

Community Group or Organisation

Are you representing a community group or organisation?

Required

What is the name of your community group or organisation?

Agreement

I apply to be a member of Locala Health & Wellbeing and be bound by the rules of the organisation. I give consent to the processing of my information.

Required

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