Child Membership

IDFA Membership Application Form - Child Patient and Main Carer

To be apply for an IDFA Child membership, you must be a resident of Australia and have a child with 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:

Child membership applications must include details of at least one of their main carers. Multiple primary carers are welcome to apply – at the end of the mandatory sections there is an option to attach up to 3 more carers to this Child Member.
IDFA processes membership applications within 4 business days. If we require further information to process your application, we will be in contact.

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Child's 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
- N/A
What is their Occupation?*
What are they Studying?*
Child's Contact Details
Child Communications Consent*
- My child is between 16 to 18 years of age and I give permission to IDFA to email my Child directly so long that I am also kept in the loop of all the communications.
- My child is between 16 to 18 years of age but I would only like IDFA to contact me.
- My child is under 16 and IDFA can contact me.
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
Main Carer Personal Details
Main Carer Full Name*
First Name Surname
Main Carer Preferred Name:
Main Carer Title (Miss/Ms, Mrs, Mr, Dr, Prof, etc):
Main Carer Pronouns:
Main Carer Date of Birth:*
DD slash MM slash YYYY
Main Carer Relationship to Child Member:
Main Carer Sex:*
- Female
- Male
- Intersex
- Prefer not to say
Main Carer First Nations:*
- Aboriginal
- Torres Strait Islander
- Prefer not to say
- Neither
Main Carer Nationality:
In case we need to access cultural support services.
Main Carer Languages:
Main Carer Working Status:*
- Full time
- Part time
- Unable to work
- Studying
Main Carer's Occupation?*
What is the Main Carer Studying?*
Main Carer Contact Details
Main Carer Email:*
Main Carer Mobile Phone:*
Main Carer Alternate Contact Number:
Main Carer Name on Social Media (Facebook):
If different to legal name so we can ensure to add the main carer to our IDFA Connect Groups.
Main Carer Residential Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Main Carer Postal Address
Select if different to above
Main Carer Postal Address:*
Street Address Address Line 2 Suburb State/Territory Postcode Country
Other Carer Personal Details
Do you have any other Carers you would like to list for your Child? This could be a family member or friend that assist your child with day to day living.*
- Yes
- No
What details would you like to share for this 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 Relationship to Child Member:
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 the Carer's Occupation?*
What is the 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 for the child. This could be a family member or friend that assist your child with 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 Relationship to Child Member:
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 is 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 add them 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 for the child. This could be a family member or friend that assist your child with 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 Relationship to Child Member:
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
Child's 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 Child's immune-related diagnosis or diagnostic status:*
- Primary Immunodeficiency
- Immunodeficiency due to the another condition. For example diagnosed with cancer
- They have symptom’s and we are currently in the discovery phases of any diagnosis
- Immune Dysregulation
Please identify their 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 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 Providers oversee your Child's 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
- Other (please list)
- I prefer not to disclose
Name of Hospital:
Please list where they receive Treatment?
Please select any Co-morbidities they 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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Child Membership

IDFA Membership Application Form - Child Patient and Main Carer

Child's Personal Details

Child's Contact Details

Main Carer Personal Details

Main Carer Contact Details

Other Carer Personal Details

Carer Contact Details

Carer 2 Personal Details

Carer 2 Contact Details

Carer 3 Personal Details

Carer 3 Contact Details

Child's Medical Information

General Information