Please add your details to the Australian Polio Register today

Polio Australia encourages every polio survivor living in Australia (whether you contracted polio in Australia or overseas) to join the Australian Polio Register.  Our strength lies in our numbers – please help us to get you the services you need by completing the form below.

You can also download a PDF version of the Australian Polio Register Form if you (or a family member / friend without internet access) would prefer to complete the form by hand and mail it to: Polio Australia, PO Box 500, East Kew Vic 3102.

Before completing the Australian Polio Register Form you can check  this page  to make sure that you haven’t previously submitted a Registration (note that an entry will only appear on that page if you have given Polio Australia permission to publish your polio details).


* indicates a required field

Please leave this field empty.

* Your Given Names

* Your Family Name (in CAPITAL LETTERS please)

Maiden Name (if applicable - CAPITAL LETTERS please)

* Sex
 Male Female

* Year that you were born

* Year that you contracted polio

Age when you contracted polio (years and months)
   

Location where you contracted polio (Suburb/Town, and Australian State if applicable)
   

Country where polio contracted (only complete if not Australia)

* Were you hospitalised when you contracted polio?
 Yes No Don't Know

If "Yes", which Hospital(s) (if known)?

* In which State/Territory are you currently living?

* Are you a member of your State Polio Network?
 Yes No

If you belong to more than one State Network, please indicate the additional States here

* If you are not a member of your State Polio Network, would you like to be put in touch with your State organisation?
 Yes No Not Applicable

If you answered "Yes", please provide your postal address and phone number(s) here (not published)

*Please tell us how you heard about the Australian Polio Register (additional details can be provided below)
 Note that if desired you can select more than one option by holding down the Ctrl key on your keyboard while you click

Please include any other details here regarding how you heard about the Australian Polio Register

If you wish to include any additional comments with your registration please enter them here (not published)


* Your email address (not published)

* If you are happy to have your name and polio details published # on this site, please click "Yes".
* If you click "No" instead, your collected data will only be published in anonymous aggregate form.
*
 Yes No

# If you click "Yes", only these details are published: family name, maiden name (if applicable), given names, birth year, year in which polio contracted, age at which polio contracted, and location where polio contracted.

Thank you for completing this form. To now send your details through to Polio Australia, please tick the box below to confirm you are not a web robot, then click the "Submit your details" button beneath.

After submitting the form you should see a message (in a box with a green border, below the "Submit your details" button and just above the horizontal line) saying "Your registration was submitted successfully. Thanks.", the details you submitted will be cleared from the form, and you will be re-directed to a "thank you" page. If you instead receive a "validation error" message, please re-load a blank register form by clicking here and try again, being careful to answer every required question (all those marked with *).

Once the form has been successfully submitted, a copy of the details that you entered will also be emailed to you for your records.


If you strike a difficulty in submitting this form that you cannot resolve, you can download a PDF version of the Australian Polio Register Form to complete and mail to Polio Australia.  You can also contact us by phone or email or advise our Webmaster of the difficulty you experienced.