Australasian Kidney Trials Network (AKTN)
APPLICATION FOR MEMBERSHIP
Membership to the AKTN is open to clinicians and researchers involved or interested in clinical trials
in kidney disease, including epidemiologists and biostatisticians.
Surname:
Given names:
Preferred title:
Please indicate if you are a member of any of the following organisations:
Australian and New Zealand Society of Nephrology
Kidney Health Australia
Transplantation Society of Australia and New Zealand
Renal Society of Australia
Cochrane Renal Review Group
Royal Australian College of Physicians
Royal Australian College of Surgeons
Other (please list):
Preferred Contact Details
Address line 1:
Address line 2:
Address line 3:
City/Suburb:
Postcode:
State:
Country:
Phone (work):
Phone (mobile):
Fax:
Email:
Current University and/or Hospital Appointments:
Qualifications (Degrees/Diplomas etc.):
Special interests in renal health:
AKTN Privacy Policy
The Australasian Kidney Trials Network complies with the national privacy legislation, The Privacy Amendment
(Private Sector) Act 2001 effective 21 December 2001.
Personal information is collected on membership application forms. All personal information will be treated in
accordance with the National Privacy Principles.
The Operations Secretariat of the AKTN will only disclose preferred contact details, including mailing address,
phone numbers and email, to other AKTN members.
Should information be requested by other parties, such as sponsors of the AKTN, permission will be sought
from network members. Permission will only be sought for purposes deemed approved by the Scientific
Committee.
Personal information about members may only be provided if the person has authorised the network to
provide it for a purpose covered by the authority given.
By completing and signing this form you give the AKTN consent for your preferred contact details to be
available on the password-protected area of the AKTN website, and for the AKTN to supply personal
information as necessary to process your application to join the network and to supply the personal
information as outlined above.
I agree to abide by the Policies and Regulations of the Australasian Kidney Trials Network.
Signature:
Please email signed document to: j.parry@uq.edu.au,
Or fax to: +61 7 3176 5663,
Or mail to:
Australasian Kidney Trials Network
School of Medicine
University of Queensland
Level 1, Building 33
Princess Alexandra Hospital
Ipswich Rd
Woolloongabba QLD 4102
Date: