Carer Membership Form

Name

This field is for validation purposes and should be left unchanged.

Your Personal Details

Full Name*

First Name Surname

Preferred Name:

Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):

Relationship to the Child/Adult you Care for:*

Full Name of the Child/Adult you Care for:*

First Name Surname

Date of Birth:*

Sex:*

Female
Male
Prefer not to say

First Nations:*

Aboriginal
Torres Strait Islander
Prefer not to say
Neither

Nationality:

In case we need to access cultural support services.

Languages:

Working Status:*

Full time
Part time
Unable to work
Studying
N/A

What is your Occupation?*

What are you Studying?*

Your Contact Details

Email:*

Mobile Phone:*

Alternate Contact Number:

Name on Social Media (Facebook/Discord):

If different to legal name so we can ensure to add you to our IDFA online groups.

Residential Address:*

Address Line 1 Address Line 2 Suburb State/Territory Postcode Country

Postal Address

Select if different to above

Postal Address:*

Postal Address Line 1 Postal Address Line 2 Postal Suburb Postal State/Territory Postal Postcode Postal Country

Dependent's Personal Details

Who are you a Carer to?*

Child
Adult

Consent*

I understand that sending this profile, IDFA will need to check if the adult needs assistance. The information below does not belong to the carer.*

Consent*

I understand this will not create an additional child/adult membership, and to do so I will need to have either the child application or adult application sent through separately. The information below is just for verification and understanding the carer type of support IDFA can tailor for me.*

Dependent's Full Name*

First Name Surname

Dependent's Preferred Name:

Dependent's Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):

Dependent's Date of Birth:*

Dependent's Sex:*

Female
Male
Prefer not to say

Dependent's First Nations:*

Aboriginal
Torres Strait Islander
Prefer not to say
Neither

Dependent's Nationality:

In case we need to access cultural support services.

Dependent's Languages:

Dependent's Working Status:*

Full time
Part time
Unable to work
Studying
N/A

What is their Occupation?*

What are they Studying?*

Dependent's Contact Details

Dependent's Email:

Dependent's Mobile Phone:

Dependent's Alternate Contact Number:

Dependent's Name on Social Media (Facebook/Discord):

If different to legal name so we can ensure to add them to our IDFA online groups.

Dependent's Residential Address:*

Address Line 1 Address Line 2 Suburb State/Territory Postcode Country

Dependent's Postal Address

Select if different to above

Dependent's Postal Address:*

Postal Address Line 1 Postal Address Line 2 Postal Suburb Postal State/Territory Postal Postcode Postal Country

Dependent's Medical Information

This information is collected to allow IDFA to provide you and the person you care for with appropriate care and support. Based on the dependent's current condition/diagnosis, please complete the questions below. Here is a link to help you determine whether the dependent may have a Primary Immunodeficiency: Primary Immunodeficiency (PID) – Australasian Society of Clinical Immunology and Allergy (ASCIA).

Please select the option that best reflects the Dependent's immune-related diagnosis or diagnostic status:*

Primary Immunodeficiency
Secondary Immunodeficiency due to the another condition
They have symptom’s and are currently in the discovery phases of any diagnosis
Immune Dysregulation

Please identify their Primary Immunodeficiency:

Please list other:*

Please state their Secondary Immunodeficiency:*

Please provide us with some more information:

Please advise what type of Immune Dysregulation they have:*

Age at Diagnosis (if applicable):

Which Healthcare Professionals oversee their care?

GP
Immunologist
Other Specialist (please list)

Name of their GP:*

Name of their Immunologist:*

Please list other Specialist type:*

Name of their Specialist:*

Are they receiving any Treatment?

Yes
No
I prefer not to disclose

Type of Treatment:*

IVig
SCig
Bone Marrow Transplant
Antibiotics
Steroids
Gene Therapy
Gammainterferon
Other (please list)
I prefer not to disclose

Please list other Treatment:

Do they receive Treatment in the Hospital, Home or other?*

Hospital
Home
I prefer not to disclose

Name of Hospital:

Please select any Co-morbidities they experience:*

Please list other Co-morbidities:

Other Medical information or challenges you may want to advise us or comment on:

General Information

How did you find us?*

Internet Search
Event (Please list)
IDFA Member
Networking (Please list)
IDFA Collateral
Other Healthcare Professional
Social Media
Word of Mouth

Please list the event where you found us:

Please list the networking occasion where you found us:

Why would you like to join IDFA?*

Consent to Receive Marketing Communications

I consent to receive marketing communications from Immune Deficiencies Foundation of Australia.

By providing your contact information and selecting the consent box above, you agree to receive marketing communications from the Immune Deficiencies Foundation of Australia via email, SMS, phone, or other digital channels. These communications may include news, offers, promotions, and updates about our products and services.

You may withdraw your consent at any time by clicking the “unsubscribe” link in our emails or by contacting us via email at info@idfa.org.au.

Consent to Privacy Policy*

I agree and understand to the privacy statement.

Your personal information will be handled in accordance with our Privacy Policy.

Would you be interested in sharing your story with the IDFA Community?*

Yes, I would like to contribute a short clip of me saying the IDFA motto of "I don't feel alone"
Yes, I would like to be contacted to share my full story.
No, I do not want to share a clip or my story.

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Carer Membership

IDFA Membership Application Form - Carer

Your Personal Details

Your Contact Details

Dependent's Personal Details

Dependent's Contact Details

Dependent's Medical Information

General Information