First Name: *

Last Name: *

Please choose which best reflect your identity: *

Parent/carer

Youth

Email Address: *

Year of Birth:

Do you live in Western Australia? *

Yes

Postcode: *

I agree to being contacted by the EMBRACE @ Telethon Kids Institute team *

*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.

What are your preferred pronouns?

Sex assigned at birth:

Male

Female

Gender:

Male

Female

Non-binary

Other

Sexuality:

Do you identify as an Aboriginal and/or Torres Strait Islander?

What is your cultural background?

Are you a migrant or refugee?

Yes

Do you have a history of chronic physical conditions? If yes, please list.

Do you have a history of mental health concerns? If yes, please list.

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

Participating in research

Receiving regular updates on the work of Embrace

Advising on the future of our research

Attending events

Becoming an Embrace community ambassador

Other (please outline reason below)