Consumer registration of interest

Personal details

First name *

Last name *

Street address

City

State

Postcode

Email *

Main contact number *

Alternative contact number

Demographic information

Gender identity *

• Male
• Female
• Non binary
• Prefer not to say

Prefer to self describe

Do you identify as Aboriginal or Torres Strait Islander?

• Aboriginal
• Torres Strait Islander
• Neither
• Prefer not to say

Age range *

• Under 30 years of age
• 30-45
• 45-65
• Over 65

Location where you spend most of your time (postcode) *

Metro, regional or rural/remote? *

• Metro
• Regional
• Rural/remote

Lifestyle

Please tick which best applies to your current circumstances *

• Student
• Employed
• Not employed
• Retired
• Other (please provide detail in text box below)

Other

Briefly outline your occupation or interests, including previous roles, if now retired or currently not employed

Experience

Have you had previous experience as a cancer consumer (ie patient, family member, friend or caregiver)? *

• Yes
• No

Are you a member of any other cancer research groups or consumer organisations? *

• Yes
• No

If yes, please provide details (name of group/s, your role and recent activities)

Please describe any committee or working group you have not described above (it doesn't need to be related to cancer)

Which of the following describes your experience with cancer (if any)? *

• Diagnosed with cancer myself
• Cancer survivor
• Carer
• Family member diagnosed
• No experience with cancer
• Other (please provide details in the text box below)

Other

Please provide details of your cancer experience (if any)

Are there any research areas you are particularly interested in? Please select all that apply

• Health planning
• Prevention and early detection
• Detection and diagnosis
• Treatment
• Survivorship, recurrence and end of life care

Life skills - personal and professional

Please describe how your life skills may contribute to our research activities

Availability to participate

Please select how you would like to participate (please select all that apply)

• Reviewing a new research idea (online)
• Reviewing a new research idea at a workshop
• Reviewing a research project grant application
• Reviewing plain language summaries of project results for the public
• Joining a project as part of the project team or steering committee
• Being a community advocate for research within my community

Communication from UMCCR

Would you be interested in receiving news and updates from UMCCR?

• Yes
• No

If you are human, do not fill in this field