Fields marked with an asterisk

are required for registration.

How to address and contact you

First Name

Last Name

Preferred Name

Contact phone number

Contact Email address

Re-enter Email

Email Calc

Email addresses do not match.

How you might like to be involved and why you are interested

This information will be used to help determine the best ways to engage with you.

What experience do you have that you would like to share? (tick any that apply):

My personal experience of a health condition, illness or diseaseMy personal experience of caring for someone with a health condition, illness or diseaseA general interest in health(care) and medical researchI represent a body of health consumers/ community membersOther (please specify)

Other experience:

If you are a consumer representative, which group(s) or organisation(s) do you represent?

Please specify the reason(s) for your interest in being involved in health and medical research at The George Institute, Australia.
(Note: you may wish to include any lived experiences or we can discuss this with you later, if you prefer).

Questions that will assist us with achieving a diverse consumer and community network

Postcode

State/Territory

Year of Birth

YOB Check

Invalid Year of Birth - You must be over 18 years old

Invalid Year of Birth - Enter the year in the format YYYY

How do you describe your gender?

Preferred gender description

Are you of Aboriginal or Torres Strait Islander origin

In what country were you born?

What languages do you speak at home?

Is there anything else related to your cultural background that you would like us to know about?

Additional Information

How did you hear about The George Institute Australia's Consumer & Community Network?

Is there anything else you would like us to be aware of?

Consumer declaration

To register your interest in becoming a member of The George Institute’s Consumer and Community Network, you:

confirm that your are aged 18 years or older;
confirm that all information you have given in this form is accurate;
consent to your personal details being added to the Consumer and Community Network Register;
confirm that you have read and understood the Privacy Notice and consent to the collection, use and disclosure of your personal information as set out in that Privacy Notice;
consent to The George Institute handling your personal information in accordance with the Privacy Policy which can be found online here.

I agree

You must be over 18 years old

Email addresses do not match.

Consumer and Community Network Register

Privacy Notice: Australia

By registering your interest in becoming a member of The George Institute’s Consumer and Community Network (CCN), your personal information, including your names, contact details, gender, date of birth, and other demographics as well as certain personal health information, knowledge and experience, will be provided to The George Institute for Global Health (TGI, we, our).

TGI is committed to handling your personal information in accordance with the Australian Privacy Principles (APPs) (Privacy Act 30%8 (Cth)) and Health Privacy Principles (HPPs) (Health Records and Information Privacy Act 2002 (NSW) and Health Records Act 2001 (VIC). This notice provides further details about how we handle your personal information.

Who is collecting your personal information?

The George Institute for Global Health (TGI)

Address: Level 18, International Tower 3, 300 Barangaroo Avenue, Sydney NSW 2000

Email: privacy@georgeinstitute.org.au

The personal information needed for us to consider you for inclusion in our CCN is collected directly from you.

Additional personal information will be collected directly from you by TGI staff during the registration process.

Why are we collecting and using your personal information?

Your personal information will be collected, used, stored and disclosed for the purposes associated with registering to become, and if registered, being, a member of the CCN, and potentially other forms of consumer involvement at TGI, which will be mutually agreed at the time of your engagement.

Specifically, we may collect and use your personal information for:

· managing the CCN registration process,

· determining your suitability for CCN membership,

· communicating with you on the status of CCN membership,

· communication with you regarding the CCN,

· responding to your enquiries and requests,

· contacting you about involvement in other consumer and community involvement initiatives.

What will happen if you do not wish to provide your personal information?

We will not be able to consider your registration for membership to the CCN, grant you membership to the CCN and/or engage with you in relation to the CCN.

Who might we disclose your personal information to?

We may disclose your personal information to TGI staff including the Consumer and Community Involvement Program Team, TGI Executive and any support staff involved in the registration and on-boarding of CCN members.

Will your personal information be disclosed to overseas recipients?

If you are granted membership to the CCN, your personal information may be disclosed to TGI staff located overseas. Your personal information will not otherwise be disclosed to overseas recipients without your prior consent.

How can you access and correct your personal information or make a complaint about a breach of the Australian Privacy Principles?

TGI’s privacy policy contains information about how you can access your personal information TGI holds and how you can request correction of any inaccurate information.

Our privacy policy also contains information about how you can make a complaint about the handling of your personal information and how we will deal with such complaint.

You can find a copy of The George Institute for Global Health’s privacy policy online at: https://georgeinstitute.org/privacy-policy

By ticking the box, you confirm that you have read and understood this Privacy Notice and consent to the collection, use and disclosure of your personal information as set out in this Privacy Notice.