Please choose which best reflect your identity: *






Do you live in Western Australia? *



*Individuals under 18 years of age must provide written consent from a parent/guardian to receive communications from the EMBRACE @ Telethon Kids team. Please complete the Parent, Carer and Guardian Consent Form and return it to embrace@telethonkids.org.au.

Sex assigned at birth:


Gender:








Are you a migrant or refugee?







Why are you interested in becoming a Community Group member? (Tick all that apply)