Narcolepsy Australia Membership Application (Confidential) If your membership application is approved you will receive a confirmation email with your membership number. Question Title * 1. Full Name Question Title * 2. Street Address Question Title * 3. State and Postcode Question Title * 4. Contact Phone Number Question Title * 5. Email Address Question Title * 6. Date of Birth (Demographic Question Only) Question Title * 7. Please indicate which response best describes your connection with Narcolepsy I have been diagnosed with Narcolepsy I have a relative or loved one who has been diagnosed with Narcolepsy I suspect that I or a relative/loved one may have Narcolepsy Other (please specify) Question Title * 8. If you have been diagnosed with Narcolepsy how long have you been diagnosed? Less than 1 year 2-5 years 5-10 years 10+ years Question Title * 9. If diagnosed who is your current treating sleep specialist? Question Title * 10. Which of the following do you suffer from (if any) Cataplexy Hallucinations Sleep Paralysis Automatic Behaviour Memory Loss None of the above/Not Applicable Other (please specify) Question Title * 11. Would you be interested in receiving email updates/info sheets and newsletters if they were available? Yes No Question Title * 12. Would you be interested in attending Support Group Meetings or Social Catch Ups in your region if they could be arranged? Yes No Question Title * 13. Are you happy to have your name and email address passed on to other members in your region? Yes No Question Title * 14. Would you like to receive a complimentary "Narcolepsy Awareness"/narcolepsysupportaustralia.com silicone wristband? Yes No Question Title * 15. How did you hear about Narcolepsy Support Australia? Facebook Friend Referral Internet Search Specialist Referral Other (please specify) Done
