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Continence Consumer Network application form

Complete the form to express interest in becoming part of our Continence Consumer Network.

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Continence Consumer Network
CCN application form

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Continence Health Australia welcomes people from a diverse range of backgrounds to enhance our work in improving bladder and bowel control for people in Australia. Share your experience of incontinence and make a difference. For assistance completing this form or for any questions please email consumer@continence.org.au

Personal details

First name

Last name

Email

Mobile

Street

Suburb

State

Postcode

Country

Your experience

I am

A person with lived experience of incontinenceA carer of one or more people with lived experience of incontinenceA person who is interested in bladder and bowel control health

Tell us a little about what you know about continence health

In the last 6 months have you or the person you care for ever used the following from Continence Health Australia?

ServicesInformationResources

Please select the areas that relate to your personal experience of incontinence.

bladder/urinary incontinencebowel incontinencecaring for an adult/s with incontinencecatheter useconstipationincontinence and chronic conditionsincontinence and disabilityincontinence after giving birthincontinence and pelvic floor muscle dysfunctionincontinence and prolapseincontinence and prostate issuesparenting a child/children with incontinencetoilet training a child/children in the past 5 years

Your involvement

I would like to

Read and comment on resources

Be part of a working group or committee

Share my story

Give feedback on advertising campaigns

Unsure, but I'd like to be involved

How often do you want to be involved?

Once or twice a yearSeveral times a yearMonthlyFortnightly

More personal details

Please select your age range

18-24 years	25-29 years
30-39 years	40-49 years
50-59 years	60-69 years
70-79 years	80-89 years
90 years +

Gender

Woman or FemaleMan or MaleNon-binary[I/they] use a different termPrefer not to answer

Gender term to be used

Country of birth

Language/s spoken

Are you of Aboriginal or Torres Strait Islander origin?

NoBothAboriginalTorres Strait Islander

Do you need any adjustments to help you access online or in person events (large font etc)?

Yes

No

If you answered yes to the previous question please tell us more about your access needs.

Do you have a disability?

Yes

No

Does the person you care for have a disability?

Yes

No

I give permission for Continence Health Australia to share news with me about the Continence Consumer Network in the following way/s

By emailBy phone

For assistance completing this form or for any questions please email consumer@continence.org.au

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About incontinence
Living with incontinence
Help and support
Resources and tools

Get involved
For health professionals
About us

Related sites

Pelvic Floor First
National Public Toilet Map
Continence Support Now
Bins4Blokes
Go Against the Flow

Contact us

Suite 1, 407 Canterbury Road,
Surrey Hills, VIC 3127

Telephone: 03 8692 8400

Fax: 03 9380 1233

National Continence Program – an Australian Government initiative

Continence Health Australia (formerly the Continence Foundation of Australia) is a registered charity and is accredited by the Australian Charities and Not-for-profits Commission.

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Continence Health Australia acknowledges the Traditional Owners of Country throughout Australia and recognises their continuing connection to lands, waters and communities. We pay our respect to their Elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

See how we support First Nations people

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