Aged Care Complaints CommissionerComplaints Matter27 April 2017

Participant Registration Form

Thank you for your interest in Complaints Matter. We hope you will find the day informative and you leave with a greater understanding of the power of complaints and why they matter.

If you have any concerns about the information we are collecting, please see our privacy policy available on our website.

Participant details

Name:
Company (if applicable):
Position (if applicable):

Contact details

Contact number:
Email:
Address:

Dietary requirements

Do you have any dietary requirements? / Yes/No – please circle correct option
If yes, please indicate.

Other

Do you identify as requiring assistance? / Yes/No – please circle correct option
If so, please let us know how we can help you.

Thank you for participating in the Aged Care Complaints Commissioner’s EventComplaints Matter.

If you have any questions or concerns please contact Lauren McGrath on (02) 9263 3610 or
email us at

CONSENT FOR USE OF PHOTOGRAPHS
AND RECORDINGS

The Aged Care Complaints Commissioner is tasked with providing information about aged care complaintsissues in the community, promoting efficient complaints management, and publicising the role of the Complaints Commissioner. As part of this communication role, the Complaints Commissioner uses photos, digital images, video and audio recordings in various publications, campaigns, advertising and on our website.

The Complaints Commissioner seeks your consent to use photos, digital images, audio or video recordings taken of you for use in these communication initiatives (the ‘Agreed Purpose’).

Acknowledgement and consent

I acknowledge that I:

  • am over the age of 18 years OR I am the parent/guardian of a person who is under 18 years and have the legal authority to give consent;
  • have read the contents of this form and know that I will receive a copy of it if I so request;
  • understand the Agreed Purpose of publication of images or recordings of me, including possible use on the Internet;
  • understand that the Complaints Commissioner does not guarantee that any images or recordings will necessarily be used;
  • understand that copyright in the images or recordings will vest in the Commonwealth of Australia;
  • understand that I will not be given the original of the image or recording of me;
  • consent to the Complaints Commissioner giving my image or recording to an Australian Government department or agency; and
  • consent to the publication, by the Complaints Commissioner, of images or recordings of me for the Agreed Purpose with any reasonable retouching or alteration.

Name: ______Signed: ______Date: _____/_____/_____

(Please print)

Please tick the box if you identify yourself as person of Aboriginal or Torres Strait Islander descent 

Phone no: ______

To enable us to reference your image in photographs if necessary, please provide a brief identifying description of you, such as hair colour, glasses, clothing type and colour.

______

______

Note: The Complaints Commissioner is required to comply with the Australian Privacy Principles under Schedule 1 of the Privacy Act 1988 when collecting personal information about you. Personal information includes photos and recordings. The Complaints Commissioner can be contacted by telephone on 0401 663548 in relation to media enquiries or issues.

The Complaints Commissioner has an APP privacy policy which you can read at .The APP privacy policy contains information about how you may access the personal information the Complaints Commissioner holds about you and how you can seek correction of it; and how you may complain about a breach of the Australian Privacy Principles.

The Complaints Commissioner is unlikely to disclose your personal information to overseas recipients.

The Complaints Commissioner makes every effort to comply with the Guidelines for Federal and ACT Government World Wide Websites available at . You should understand that personal information published on the Internet is accessible to anyone with access to the Internet, from anywhere in the world. While the contents of the Complaints Commissioner’s web site are protected by copyright, once information has been published on the Internet, the Complaints Commissioner has no control over its subsequent use and disclosure.

Complaints Matter Participant Registration Form