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:

I would like to be involved as a (tick any that apply):

Health consumer i.e. someone who directly or indirectly makes use of health servicesCarer of someone with a health conditionConsumer representative i.e. someone who voices consumer perspectives and takes part in the decision-making process on behalf of consumers. This person may be nominated by, and may be accountable to, an organisation of consumersIndividual without a known health condition, who has an interest in contributing to health researchPerson who identifies as being a member of a particular societal or community-based group e.g. Aboriginal and/or Torres Strait Islander person, person from a culturally or linguistically diverse community, LGBTQI community, rural or remote community

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

Specify Other interest in programs of work at The George:

If you are interested in specific area(s) or types of health research, please specify:

If you have a specific role in mind, or are responding to a particular request to become involved, please indicate here. Note: you can tick as many as you like but answering this question is not essential - we can discuss this with you in more detail.

Consumer and Community Network memberConsumer and Community Advisory Committee memberConsumer Panel member for a particular program of workProject Steering Committee or Reference Group memberHealth Consumer Partner or Co-investigatorAboriginal or Torres Strait Islander research roleUnsureOther

Specify other role of interest

Please specify the reason for your interest. Note: You may wish to include any relevant health issues or medical conditions that you, or someone close to you have experienced, or are at risk of developing.

Please briefly describe any current involvement with community groups.

The following information will help us achieve 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

What gender do you identify with?

What pronouns do you use?

Specify other pronoun

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 and agreement

The information you provide on this form will be stored securely in the Consumer and Community Network Register. This information will be treated confidentially and only be accessed by authorised staff, i.e. the Consumer and Community Involvement Program, The George Institute for Global Health, Australia. You will be contacted by a team member after you have registered to confirm the details of your involvement in the Consumer and Community Network.

I confirm that:

I am aged 18 years or older;
All information I have given in this form is accurate;
I consent to my details being added to the Consumer and Community Register and to The George Institute handling my personal information in accordance with the Privacy Policy which can be found here;
I may be sent information or contacted regarding my role in The Institute's research (or research-related) activities. I understand that I may revoke this consent at any time in writing by email to cci@georgeinstitute.org.au or privacy@georgeinstitute.org.au;
I agree that The George Institute may send me information about its work and the Consumer and Community Network. I can opt out anytime.