* 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
---1910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

* Year that you contracted polio
---Not Known1910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

Age when you contracted polio (years and months)
000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950     000102030405060708091011

Location where you contracted polio (Suburb/Town, and Australian State if applicable)
    ---Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia

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?
---Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia

* 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
Polio Australia websitePolio Australia online petitionPolio Australia Facebook pagePolio Australia Twitter pagePolio Australia publication (please give details)Other Polio Australia publicity (please give details)A State Polio Network (please give details)A local Polio Support Group (please give details)Another polio survivorFamily member or friendNewspaper or magazine article (please give details)Radio or TV item or interview (please give details)Other (please give details)

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 complete the puzzle below and then click the "Submit your details" button.

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 message was sent successfully. Thanks." and the details you submitted will be cleared from the form. 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.

Thank you for joining the Australian Polio Register. If you have given Polio Australia permission to publish your polio details they will be accessible  online here  within 24 hours of submission. If you chose to have your details included only in the anonymous aggregate data, the published data will likewise reflect your input within 24 hours.