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CONNECT.ed Registration Form

All data collected in this survey allows Injury Matters to complete your CONNECT.ed registration, improve the CONNECT.ed network and increase our understanding of CONNECT.ed participants.

If you require any information about this registration process or CONNECT.ed please contact Injury Matters via info@knowinjury.org.au or (08) 6166 7688.
1.What is your first name?(Required.)
2.What is your last name?(Required.)
3.What is your organisation?(Required.)
4.What is your position?(Required.)
5.I identify my gender as:(Required.)
6.Please select your age group(Required.)
7.Are you of Aboriginal or Torres Strait Islander origin?(Required.)
8.How long have you been involved in the injury prevention field and/or safety promotion field?(Required.)
9.What best describes the type of organisation you work for?(Required.)
10.What area of injury prevention do you mainly work in?(Required.)
11.What is your country of residence?(Required.)
Country of Residence
12.If in Australia, what is the postcode of your workplace?(Required.)
13.How did you hear about CONNECT.ed? (Select all that apply)(Required.)
14.Do you consent for the information and data you provide to be used in the evaluation?(Required.)
15.Do you consent to be contacted again for the purpose of evaluation?(Required.)
16.Can we please have your email address?(Required.)
17.Can we please have your phone number?
18.As a participant of CONNECT.ed I agree to Spark Collaborations Terms and Conditions (Required.)