Adult Membership

IDFA Membership Application Form - Adult Patient

To be an IDFA adult member you must be a resident of Australia and have a diagnosis of a primary or secondary immunodeficiency.

If you are unsure whether your diagnosis qualifies for membership, you may visit the below website for a list of primary immunodeficiency variants.

ASCIA
IDF

Please note:

IDFA processes membership applications within 4 business days. If we require further information to process your application, we will be in contact.
Your main carer is also welcome to apply for membership to stay up to date with IDFA’s resources and offerings. They will have to fill out separate Carer Membership form.

Email
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):
Pronouns:
Date of Birth:*
DD slash MM slash YYYY
Sex:*
- Female
- Male
- Intersex
- 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
What is your Occupation?*
What are you Studying?*
Your Contact Details
Email:*
Mobile Phone:*
Alternate Contact Number:
Name on Social Media (Facebook):
If different to legal name so we can ensure to add you to our IDFA Connect Groups.
Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Postal Address
Select if different to above
Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Spouse/Partner Personal Details
Do you have a Spouse/Partner?*
- Yes
- No
What details of your Spouse/Partner would you like to share?*
- Their name only
- I would like to register my Spouse or Partner as a Carer member for the purposes of receiving communications from IDFA
- None
Spouse/Partner Full Name*
First Name Surname
Spouse/Partner Preferred Name:
Spouse/Partner Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):
Spouse/Partner Pronouns:
Spouse/Partner Date of Birth:*
DD slash MM slash YYYY
Spouse/Partner Sex:*
- Female
- Male
- Intersex
- Prefer not to say
Spouse/Partner First Nations:*
- Aboriginal
- Torres Strait Islander
- Prefer not to say
- Neither
Spouse/Partner Nationality:
In case we need to access cultural support services.
Spouse/Partner Languages:
Spouse/Partner Working Status:*
- Full time
- Part time
- Unable to work
- Studying
What is your Spouse/Partner's Occupation?*
What is your Spouse/Partner Studying?*
Spouse/Partner Contact Details
Spouse/Partner Email:*
Spouse/Partner Mobile Phone:*
Spouse/Partner Alternate Contact Number:
Spouse/Partner Name on Social Media (Facebook):
If different to legal name so we can ensure to add them to our IDFA Connect Groups.
Do you and your Spouse/Partner share the same Residential Address?*
- Yes
- No
Spouse/Partner Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Do you and your Spouse/Partner share the same Postal Address?*
- Yes
- No
Spouse/Partner Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Carer Personal Details
Do you have any other Carers you would like to list? This could be a family member, child or friend that assist with you your day to day living.*
- Yes
- No
What details would you like to share for your Carer?*
- Their name only
- I would like to register them as a Carer member for the purposes of receiving communications from IDFA
- None
Carer Full Name*
First Name Surname
Carer Preferred Name:
Carer Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):
Carer Pronouns:
Carer Date of Birth:*
DD slash MM slash YYYY
Carer Sex:*
- Female
- Male
- Intersex
- Prefer not to say
Carer First Nations:*
- Aboriginal
- Torres Strait Islander
- Prefer not to say
- Neither
Carer Nationality:
In case we need to access cultural support services.
Carer Languages:
Carer Working Status:*
- Full time
- Part time
- Unable to work
- Studying
What is your Carer's Occupation?*
What is your Carer Studying?*
Carer Contact Details
Carer Email:*
Carer Mobile Phone:*
Carer Alternate Contact Number:
Carer Name on Social Media (Facebook):
If different to legal name so we can ensure to add them to our IDFA Connect Groups.
Carer Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Carer Postal Address
Select if different to above
Carer Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Second Carer
Select if you have another carer you would like to list. This could be a family member, child or friend that assist with you your day to day living.
Carer 2 Personal Details
What details would you like to share for Carer 2?*
- Their name only
- I would like to register them as a Carer member for the purposes of receiving communications from IDFA
- None
Carer 2 Full Name*
First Name Surname
Carer 2 Preferred Name:
Carer 2 Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):
Carer 2 Pronouns:
Carer 2 Date of Birth:*
DD slash MM slash YYYY
Carer 2 Sex:*
- Female
- Male
- Intersex
- Prefer not to say
Carer 2 First Nations:*
- Aboriginal
- Torres Strait Islander
- Prefer not to say
- Neither
Carer 2 Nationality:
In case we need to access cultural support services.
Carer 2 Languages:
Carer 2 Working Status:*
- Full time
- Part time
- Unable to work
- Studying
What is this Carer's Occupation?*
What this Carer Studying?*
Carer 2 Contact Details
Carer 2 Email:*
Carer 2 Mobile Phone:*
Carer 2 Alternate Contact Number:
Carer 2 Name on Social Media (Facebook):
If different to legal name so we can ensure to them you to our IDFA Connect Groups.
Carer 2 Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Carer 2 Postal Address
Select if different to above
Carer 2 Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Third Carer
Select if you have another carer you would like to list. This could be a family member, child or friend that assist with you your day to day living.
Carer 3 Personal Details
What details would you like to share for Carer 3?*
- Their name only
- I would like to register them as a Carer member for the purposes of receiving communications from IDFA
- None
Carer 3 Full Name*
First Name Surname
Carer 3 Preferred Name:
Carer 3 Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):
Carer 3 Pronouns:
Carer 3 Date of Birth:*
DD slash MM slash YYYY
Carer 3 Sex:*
- Female
- Male
- Intersex
- Prefer not to say
Carer 3 First Nations:*
- Aboriginal
- Torres Strait Islander
- Prefer not to say
- Neither
Carer 3 Nationality:
In case we need to access cultural support services.
Carer 3 Languages:
Carer 3 Working Status:*
- Full time
- Part time
- Unable to work
- Studying
What is this Carer's Occupation?*
What is this Carer Studying?*
Carer 3 Contact Details
Carer 3 Email:*
Carer 3 Mobile Phone:*
Carer 3 Alternate Contact Number:
Carer 3 Name on Social Media (Facebook):
If different to legal name so we can ensure to add them to our IDFA Connect Groups.
Carer 3 Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Carer 3 Postal Address
Select if different to above
Carer 3 Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Your Medical Information
This information is collected to allow IDFA to provide you with appropriate care and support. Based on your current condition/diagnosis, please complete the questions below. Here is a link to help you determine whether you may have a Primary Immune Deficiency: Primary Immunodeficiency (PID) – Australasian Society of Clinical Immunology and Allergy (ASCIA).
Please select the option that best reflects your immune-related diagnosis or diagnostic status:
- Primary Immunodeficiency
- Immunodeficiency due to the another condition. For example diagnosed with cancer
- I have symptom’s and am currently in the discovery phases of any diagnosis
- Immune Dysregulation
Please identify your Primary Immunodeficiency:
- Ataxia-Telangiectasia
- Chronic Granulomatous Disease (CGD)
- Common Variable Immunodeficiency (CVID)
- Complement Deficiencies (e.g., C3 deficiency, C5–C9 deficiencies)
- DiGeorge Syndrome
- Hyper IgM Syndrome
- Severe Combined Immunodeficiency (SCID)
- IgA Deficiency
- Wiskott-Aldrich Syndrome
- X-linked Agammaglobulinemia
- Other (please list)
Please list other:*
Please state your Secondary Immunodeficiency:*
Please provide us with some more information:
Please advise what type of Immune Dysregulation you have:*
Age at Diagnosis (if applicable):
Which Healthcare Providers oversee your care?
- GP
- Immunologist
- Other Specialist (please list)
Name of your GP:*
Name of your Immunologist:*
Please list other Specialist type:*
Name of your Specialist:*
Are you 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 you receive Treatment in the Hospital, Home or other?*
- Hospital
- Home
- Other (please list)
- I prefer not to disclose
Name of Hospital:
Please list where you receive Treatment?
Please select any Co-morbidities you experience:*
- Bronchiectasis
- Lung Disease
- Chest Infections
- Asthma
- Sinus Infections
- Bowel Disease
- Endocrine Disorder
- Osteoarthritis
- Rheumatoid Arthritis
- Neurological Disorder
- Skin Issues
- Allergies
- Fatigue
- Depression
- Anxiety
- Autism Spectrum Disorder
- Cancer
- Other (please list)
- I prefer not to disclose
Other:
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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Adult Membership

IDFA Membership Application Form - Adult Patient

Your Personal Details

Your Contact Details

Spouse/Partner Personal Details

Spouse/Partner Contact Details

Carer Personal Details

Carer Contact Details

Carer 2 Personal Details

Carer 2 Contact Details

Carer 3 Personal Details

Carer 3 Contact Details

Your Medical Information

General Information