Consumer representative expression of interest

Title*

Given name*

Family name*

Email address*

Phone*

Country/State*

Location*

Traditional land

Employer (name)

Occupation

Skills*

As a CAG member you will be granted Associate membership of one or both of our clinical trials groups. Please tick one or both options below to indicate which group/s you wish to be a member of.*

Are you a member of any other consumer organisations?*

If yes, please list

Populations*

Symptoms*

Conditions*

Please provide the names and contact details of two people who can comment on your suitability to volunteer as a consumer representative*

I agree to the above information being saved in a confidential database to be used by IMPACCT (including PaCCSC and CST) to contact me about research opportunities, send me newsletters and invite me to events.*