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Please read the following notes regarding the privacy of the information you are asked for in this form

  1. The details collected below are used both for the Injury Support Network Organisation management and the discussion forum.
  2. All items marked with a blue star * are required for your application to be processed.
  3. For extra security only your email and alias are stored on this site.
  4. Your information will NEVER be shared with third parties for marketing.
  5. Our sign up will not accept an email address that resembles / may reveal, your name. Please go to google, and sign up for a free gmail address

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First Name *
Last Name *
Email Address *
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Password *
Confirm your password *
Forum alias *
Contact phone number *
Your address *

Please provide us with details of an emergency contact

Emergency Contact's Name *
Emergency Contact's Phone *
Emergency Contact's realtionship to you *
About your injury (please include a short summary of the nature of your injury - this information will NOT be made public)
Additional information

Acknowledgement and Consent:

I understand that by completing this form the information provided will be entered into the (offline) ISN database.
I agree by providing the information ISN may use the information to discuss my claim or injury with specialists, other providers, my insurer or Workcover and consent to the use of the information as ISN may require.
Tick this box to indicate your agreement with the above statement

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