Updated Consumer Membership Form (3) "*" indicates required fields Please note: your information will not be provided to anyone else without your permission, and you can opt-out at any time.Your DetailsTitle*Please ChooseDrProfA/ProfMrMrsMsMissMxFirst Name*Last Name*Suburb*Postal Code*State/Town*ACTNSWNTQLDSATASVICWAInternationalRegion* Metro Regional Rural / Remote Not sure Please choose which location you spend most of your time in.Email* Mobile*Gender Identity*Please chooseFemaleMaleNon-binaryPrefer not to sayCurrent Age*Please chooseLess than 30 years30-45 years46-65 yearsOver 65 yearsHow old were you or someone you cared for when they were diagnosed with cancer?*If not applicable, please write “not applicable” Priority Population GroupsThere are significant health inequities among specific population groups within Australia that lead to poorer cancer outcomes for these communities. PC4 is dedicated to including priority population groups as part of our research to help achieve health equity for all Australians. We may reach out to you if there are opportunities for involvement that align with your experiences. We invite you to share information about yourself. Your information will not be shared without your consent. All questions are optional. You may skip a question by selecting “Prefer not to say”. To learn more about the priority population groups, please visit the Australian Cancer Plan here. Do you speak a language other than English at home?* No Yes Prefer not to say What language(s)?*Do you identify as an Aboriginal and/or Torres Strait Islander?* Yes – Aboriginal Yes – Torres Strait Islander Yes – Both Aboriginal and Torres Strait Islander No Prefer not to say Are you part of the LGBTIQA+ Community (including caring for someone who is part of the LGBTIQA+ community who has had a cancer diagnosis)?* Yes No Prefer not to say Do you live or have lived experience with disability (including caring for someone with a disability who has had a cancer diagnosis)?* Yes No Prefer not to say Do you live or have lived experience with mental illness (including caring for someone with mental illness who has had a cancer diagnosis)?* Yes No Prefer not to say Your Research Interest(s)What are your area(s) of research interest?Cancer site* Bone Breast Genitourinary Gynaecological Haematological Head and Neck Hepatobiliary Lower GI Lung Metastatic Paediatric/Adolescents and young adults Rare Skin and Melanoma Upper GI Other Select AllPlease specify:*Research area* Prevention, screening and early diagnosis Treatment and shared care Survivorship and symptom management End-of-life care Carer support Other Please specify:*Consumer ExperienceHave you had previous experience as a cancer consumer?* Yes No Have you received any previous training to be a consumer representative?* Yes No Have you had experience in clinical trials as a consumer?* Yes No Where did you hear about PC4?* Word of mouth – Colleague/friend Online search Social media (LinkedIn, Twitter) Research paper Other Please specify:*Thank you for your interest in PC4!
