Select Your Country*Username*Email*First Name*Last Name*Password*Confirm Password*Phone*Address 1Townhouse / Unit Number*Address 2Street Number / Name*Suburb*Postcode*StateQueenslandNew South WalesAustralian Capital TerritoryVictoriaSouth AustraliaWestern AustraliaTasmaniaNorthern Territory*CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaSamoaYemenZambiaZimbabwe *Date of BirthPhotograph Upload Remove Do you know / are you related to an applicant / existing member ?YesNoMember NameWhat Is your relationship with the applicant / existing member ?SpouseFamily MemberGuardianFriendProfessional*Participant Member Vulnerability StatusI live with a Brain InjuryI live with AutismI am a Stroke SurvivorI live with Dementia / Alzheimer's / ParkinsonsSelect Only 1*Participant Member Impairments - SpeechI have no major speech impairmentsNon-VerbalImpaired speech or communicationDifficulty speaking or abnormal tone of voiceSpeak unrecognisable wordsDifficulty repeating phrasesInterupt others and speak rapidlySpeak in short or incomplete sentencesDifficulty finding wordsSelect ALL that apply to you*Participant Member Impairments - SightI have no major sight impairmentsBlindImpaired VisionDifficulty with recognitionDifficulty with depth perceptionVisual sensitivities to lightsSee flashes, spots, shapes and/or coloursAvoidance of eye contact or poor eye contactHazy, blurred, or double visionSelect ALL that apply to you*Participant Member Impairments - HearingI have no major hearing impairmentsDeafImpaired hearing - UnassistedImpaired hearing - AssistedAuditory overloadI can communicate with Auslan / Sign LanguageSelect ALL that apply to you*Participant Member Impairments - MemoryI have no major memory impairmentsDifficulty with memory lossDifficulty with understanding or comprehensionDifficulty with attention or concentrationImpaired judgement or decision-makingDifficulty remembering things that just happenedSelect ALL that apply to you*Participant Member Impairments - MobilityI have no major mobility impairmentsPartial ParalysisPoor coordination, balance or muscle controlImpaired mobility or physical capacityAbnormal body postureAbnormal facial expressionsDifficulty processing physical sensations or movementSelect Maximun of 3*Participant Member Impairments - CognitionI have no major cognition impairmentsUnderstand visual materials better than written or spoken wordsDifficulty understanding words other people sayDifficulty with conversationsDifficulty with language processingDifficulty with language comprehensionImpaired reading and writing abilityDifficulty processing sight and sound informationInability to plan or solve problemsPoor decision-makingDifficulty completing normal tasksFaulty reasoningSelect ALL that apply to you*Participant Member Impairments - AwarenessI have no major awareness impairmentsConfusion, disorientation or dizzinessSlow response time to informationConfusion, hallucinations, paranoia, agitationDisorientation to time and placeDifficulty understanding facial expressionsDifficulty understanding other peoples moodSelect ALL that apply to you*Participant Member Impairments - BehaviourI have no major behavioral impairmentsImpatience, anxiety or agitationDifficulty controlling anger or aggressive behaviourDifficulty controlling inappropriate behaviourDifficulty controlling social behaviourBehavioural DisturbancesEmotional SensitivitySeizures, headaches, nausea or fatigueSelect ALL that apply to you*I the Participant Member authorise my Primary Contact to act on my behalf.YesNo*I the Participant Member authorise my Secondary Contact to act on my behalf.YesNo*Applicant Accept – Terms and ConditionsI have read and accept the Terms and Conditions of Membership of Ability ID Association of Australia Inc. (link to page)*This section MUST be completed by the Applicant's Primary ContactI confirm that I am the Applicant's Primary Contact*Primary Contact First Name *Primary Contact Last Name *Primary Contact Phone *Primary Contact Email *Primary Contact - What Is your relationship with the applicant ?SpouseFamily MemberGuardianFriendProfessional*Primary Contact Accept – Terms and ConditionsI have read and accept the Terms and Conditions of Membership of Ability ID Association of Australia Inc. (link to page)*This section MUST be completed by the Applicant's Secondary ContactI confirm that I am the Applicant's Secondary ContactSecondary Contact First NameSecondary Contact Last NameSecondary Contact PhoneSecondary Contact EmailSecondary Contact - What Is your relationship with the applicant ?SpouseFamily MemberGuardianFriendProfessionalSecondary Contact Accept – Terms and ConditionsI have read and accept the Terms and Conditions of Membership of Ability ID Association of Australia Inc. (link to page)*This Section MUST be complete by a Registered Allied Health ProfessionalI confirm that I am a Registered Allied Health Professional*Participant Member – Allied Health Professional First Name*Participant Member – Allied Health Professional Last Name*Participant Member – Allied Health Professional Phone *Participant Member – Allied Health Professional Email *Participant Member – Allied Health Professional Registered QualificationsMedical PractitionerNurseOccupational TherapistPhysiotherapist PsychologistSpeech PathologistSocial WorkerSelect all that applyParticipant Member – Allied Health Professional Registered Qualifications – Other Please give details*Participant Member – Allied Health Professional Organisation / Employer Name*Participant Member – Allied Health Professional – Employer Phone *Participant Member – Allied Health Professional – Employer Email *Participant Member – Allied Health Professional Accept – Accuracy of Information ProvidedI verify that the accuracy of the information, details and photograph/s I have provided are true and correct.
