Consent | Vaccine Trials Group

FORM OF CONSENT

TO RECEIVE NEWSLETTER AND PARTICIPATION IN FUTURE RESEARCH

The Vaccines Trials Group, part of the Wesfarmers Centre of Vaccines and Infectious Diseases based at Telethon Kids Institute, is involved in the development, evaluation and promotion of vaccines in our community for children and adults. We also participate in research to further understand why some children develop allergies or frequent infections. Information regarding your family will be kept on a confidential electronic database.

Please complete the form below.

Parent Details

First Name (Required)

Last Name (Required)

Date of Birth (Required)

Mobile (Required)

Email Address (Required)

Address Details (Optional)

Home Address

Suburb

Postcode

The Vaccine Trials Group preferred method of correspondence is via email.

Would you like to receive our e-newsletter?
Yes No (Required)

1. Do you give your permission to be contacted by the Vaccine Trials Group researchers regarding future research in which you or your family members may be eligible to participate? This means that you may be invited to participate in future studies, but are free to decline.
Yes No (Required)

Please enter all family members (under the age of 18 years) for whom you give permission to receive information. (Note: Only enter the name(s) of family member(s) for whom you are a parent or legal guardian):

First Name

Last Name

Gender

Date of Birth

2. The information regarding you or your family will not be released to other parties outside Perth Children’s Hospital (PCH) and Telethon Kids Institute . Please indicate if you give permission for you or your family’s details to be shared with other research groups within PCH and Telethon Kids Institute:
Yes No (Required)

Please note: By clicking the 'I Consent' button below you are agreeing to be part of the Vaccine Trials Database. Participation in the Vaccine Trials Group database is voluntary and you can withdraw your consent at any time.