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Congratulations, you have taken the first step towards living a healthier lifestyle. Fill in your details below to join the My Healthy Balance program.

You must enter all fields marked with asterisk(*) below

Personal Details

First name:	*
Surname:
Year of birth:	*	Please Select 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Gender:	*	Please Select Male Female
State:	*	Please Select ACT NSW NT QLD SA TAS VIC WA

Postcode:

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More Details

Occupation:	*	Please Select Homemaker Student Looking for work Full time Part time Casual
Job Title:
Group you most identify yourself with:		Please Select Aboriginal or Torres Strait Islander Caucasian Other
Phone Number:
Email:	*
How did you hear about the program?	*	Please Select Health professional General practitioner Friend Internet search Newspaper/magazine/media Other
Reason for joining program:	*	To learn about healthy eating Improve diet Increase or maintain physical activity and fitness Weight management Mental health Health/wellbeing Receive support and/or motivation Other:
Are you joining the program as part of a workplace?	*	Yes No
Workplace Code:

Account Details

Password:	*
Confirm password:	*
Terms:	*	I accept the Terms and Conditions of this program