Contact Details

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Email

Mobile

Occupation

Address Line 1

Suburb

State

Postcode

About You

Tell us about your family

Are you of Aboriginal and/or Torres Strait Islander origin?

What is your cultural background / ethnicity?

What languages can you speak?

Please list all above

Are you a current PANDA Volunteer?

YesNo

Are you a parent?

YesNo

Tell us about your child/ren and their age/s?

Why would you like to become a PANDA Community Champion?

Do you have any personal or professional skills you would like to share as a PANDA Community Champion?

Did you use assisted reproductive treatments to conceive your child?

YesNo

Would you be interested in sharing your experiences?

YesNo

Were you under the age of 25 when you had your child/ren and experienced perinatal mental health challenges?

YesNo

How old were you?

Your Experiences

Share your story of perinatal mental health

Sharing your story on PANDA’s websiteSharing your story through online and traditional mediaSharing your story through PANDA’s social media posts

Media

Initiating local media activity (e.g. local papers, talkback radio)Sharing PANDA social media messages

Community Awareness

Running local awareness-raising activitiesRepresenting perinatal mental illness and PANDA to local community groups, organisations and governmentProviding a consumer voice within the community and perinatal health sectorPromoting PANDA campaignsDistributing PANDA resources to local community services and organistionsKeeping PANDA informed of relevant local activities, issues and perinatal support services

Other (if above is ticked)

Privacy Statement

PANDA collects volunteers' personal information in order to administer our volunteer programs (recruitment, supervision and support of volunteers). Please view the PANDA Privacy Policy here.