Continence Consumer Network application form

Continence Consumer Network application form

The Continence Foundation of Australia welcomes people from a diverse range of backgrounds to enhance their work in improving bladder and bowel control for Australians. Share your experience of incontinence and make a difference. For assistance completing this form or for any questions please email consumer@continence.org.au

Personal Details

First name

Last name

Email

Mobile

Street

Suburb

State

Postcode

Country

Your experience

You are

A person with lived experience of incontinenceA carer of one or more people with lived experience of incontinenceA person who is interested in bladder and bowel control health

Tell us a little about what you know about continence and incontinence

In the last 6 months have you, or the person you care for, ever used the following from the Continence Foundation of Australia?

ServicesInformationResources

Please select the areas that relate to your personal experience of incontinence.

bladder/urinary incontinencebowel incontinencecaring for an adult/s with incontinencecatheter useconstipationincontinence and chronic conditionsincontinence and disabilityincontinence after giving birthincontinence and pelvic floor muscleincontinence and prolapseincontinence and prostate issuesparenting a child/children with incontinencetoilet training a child/children in the past 5 years

Your involvement

I would like to

Read and comment on resources

Be part of a working group or committee.

Share my story.

Give feedback on advertising campaigns.

Unsure, but I'd like to be involved.

How often do you want to be involved?

Once or twice a yearSeveral times a yearMonthlyFortnightly

More Personal Details

Please select your age range

18-24 years	25-29 years
30-39 years	40-49 years
50-59 years	60-69 years
70-79 years	80-89 years
90 years +

Gender

Woman or FemaleMan or MaleNon-binary[I/they] use a different termPrefer not to answer

Gender Term to be used

Country of Birth

Language/s spoken

Are you of Aboriginal or Torres Strait Islander origin?

NoBothAboriginalTorres Strait Islander

Do you need any adjustments to help you access online or in person events (large font etc)?

Yes

No

If you answered yes to the previous question please tell us more about your access needs.

Do you have a disability?

Yes

No

Does the person you care for have a disability?

Yes

No

I give permission for the Continence Foundation of Australia to contact me about the Continence Consumer Network in the following way/s

By EmailBy Phone

For assistance completing this form or for any questions please email consumer@continence.org.au

Contact Information