Fill in and mail back the database registration form
PATRON Dr Linda Friedland DATABASE REGISTRATION FORM MEDICAL & SCIENTIFIC ADVISORY PANEL Reasons for maintaining a database of women living with LAM in Australia include: 1 Prof David Sonnabend (Convenor) being aware of women in each state of Australia who are living with LAM supporting women living with LAM (WLWL) by talking and emailing them, organising meetings and distributing news and information encouraging WLWL and their support networks to be involved in our activities. 2 Prof Judith Black AO Dr Tamera Corte Prof Allan Glanville 3 Dr Jeffrey Lindenmayer Prof Mervyn Merrilees PRIVACY STATEMENT Dr Helen Whitford Names and details provided for registration remain strictly confidential. A/Prof Deborah Yates No information provided will be provided to any person or organisation without the express permission of the individual concerned. EXECUTIVE President Janet Neustein Personal stories and other details will be published only with the full consent of the individual concerned. Vice President Melanie Hawyes Please initial the boxes, add the information requested and sign below: I have read and accept the information above. Secretary Stacey McMasters Treasurer Michael Neustein COMMITTEE Kate Burford Roxy Coward Pat Evans Gai Golder PUBLIC OFFICER Peter Kelso HON AUDITOR Peter Hersh, Logicca P/L Please add me to the database of women living with LAM in Australia. I consent to being contacted by a representative of LAM Australia. _____________ ______________________________ _______________________________________________________ TITLE FIRST NAME of FAMILY NAME OF APPLICANT (BLOCK LETTERS) _________________________________________________________________________________________________ POSTAL ADDRESS ___________________________________________ _____________ _________-‐___ ________________________ SUBURB STATE POSTCODE DATE OF BIRTH ___________________________ ______________________________ _____________________________________ TEL (H OR W?) MOBILE EMAIL NEXT OF KIN RELATIONSHIP _______________________________ ___________________________ __________________________________________ FOUNDING PRESIDENT Heather Telford EMAIL _______________________________________ __________________________________ __________________________ NAME OF SPECIALIST DATE OF DIAGNOSIS HIS/HER WORKPLACE __________________________________________________________________________ SIGNED BY APPLICANT ____________________ DATE Please mail, fax or email the completed form. Many thanks, LAM Australia Research Alliance.
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