Child patient Membership Form

Child's full name:*

Preferred name:

Parent/Carer’s full name 1:*

Parent/Carer’s full name 2:

Residential address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:*

Mobile phone:*

I wish to receive information about primary/secondary immunodeficiency on behalf of my child.

Date of Birth (child):*

Gender:

Aboriginal / Torres Strait Islander:

Nationality (in case we need to access cultural support services):

Primary language:

Please name your confirmed type of immunodeficiency eg CVID or Secondary immunodeficiency – resulting from cancer:*

Patient age at diagnosis:

Treating clinician eg immunologist:*

Type of treatment:

Other:

Main hospital for treatment:

Co-morbidities (feel free to list here):

Other:

Other significant illnesses:

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Become a Member as a Child Patient