Keratoconus Australia - Registration

Keratoconus Australia has been created to help control and prevent keratoconus and its effects within the Australian community. You can support our work by registering with the association. By filling in the registration form below, you will enable us to

keep in contact with you

to provide you with information on the latest research and developments in the treatment of keratoconus

to inform you of the association's upcoming events

expand our Australian database of people with keratoconus to assist research into keratoconus and advocacy initiatives on behalf of people with keratoconus.

You can register as either a Member or Supporter of Keratoconus Australia Inc.

Full membership is FREE and entitles you to a membership kit of useful information about keratoconus and the Association.

We believe Keratoconus Australia should be controlled by people with keratoconus and their immediate family to ensure our interests remain the focus of the Association's activities. Only Members have voting rights in the Association. To become a Member, you must either have keratoconus or be the parent or legal guardian of a child under the age of 18 years with keratoconus.

Supporters of Keratoconus Australia will receive periodic updates on our work and invitations to participate in the Association's activities.

Anybody can contact Keratoconus Australia Inc for more information about keratoconus, the Association's activities or assistance.

You can apply for membership of Keratoconus Australia only by completing the membership form below and agreeing to abide the Association's rules.

Required contact information is marked with an asterisk (*); other information is optional. All information is strictly confidential and subject to the Association's privacy policy. The form is also available for download in pdf format

By supplying personal and health information on this form, you agree to the collection of that information by the Association and its volunteers.

Membership form (required for enrolment as a Member)

First Name*

Last Name*

Street Address *

Suburb/Town*

State*

Postcode*

Country*

*I wish to become a Member Supporter of
Keratoconus Australia Inc (Association).

*If applying for member status, I certify that either
I have keratoconus
I am the parent or legal guardian of a minor with keratoconus. My relationship is

(e.g. parent or legal guardian - specify please)

*In the event of my admission as a Member, I agree to be bound by the rules of the Association.

I agree I disagree

*Date of birth(for security)

Home Phone

Work Phone

Mobile Phone

Please check button if you DO NOT want to receive occasional information bulletins about Keratoconus Australia

*Email address

*Can we send information by email?
Yes No

Your profession

Will you assist Keratoconus Australia Inc.
Yes No

Keratoconus details (optional and subject to privacy policy)

Do you have keratoconus?
Yes No

If "Yes," year first diagnosed

Have you had corneal crosslinking (CXL)
Yes
No

If "Yes," year of most recent CXL

Which eye had crosslinking?
Left Eye
Right Eye
Both

Have you had a corneal graft?
Yes
No

If "Yes," year of most recent graft

Which eye is grafted?
Left Eye
Right Eye
Both

Name of ophthalmologist

Ophthalmologist suburb

Do you wear
Glasses Contact lenses Both

Name of optometrist

Optometrist suburb

Private Health Fund

Like much information transmitted by email and internet, the information you submit here is not encrypted and may be capable of interception by third parties.