ACCF HPV and Me Program
Vaccination Provider / Health Service Registration Form

Thank you for your interest in the Australian Cervical Cancer Foundation’s HPV and Me school education program. The program provides age-appropriate education about HPV, HPV vaccination and cervical cancer prevention.

Please complete this short registration form, so we can understand who is using the program.  

This form collects vaccine provider contact and basic information only. Please do not include student names, individual student health information or vaccination records.

Estimated completion time: 5 minutes.

Section 1: Vaccination Provider / Health Service Details
School type to be provided vaccination (if applicable)
School sector to be provided vaccination (if applicable)
School region, network or diocese (if applicable)
Section 2: Main Vaccination Provider / Health Service Contact
Main Contact Person
Main Contact Name
Main Contact Role
Main Contact Email address
Main Contact Phone Number
Preferred contact method
Section 3: Program Registration Details
Has your organisation previously used the HPV and Me program?
How did you hear about the program?
Please provide the year level/s of the students you'd plan to use the program with (if applicable).
Approximately how many schools (if applicable) do you plan to deliver the course to?
If applicable, approximately how many students do you plan to present the program to?
If applicable, which formats of our presentations do you plan to use?
Section 4: Privacy and Acknowledgement

The OAIC says organisations collecting personal information should take reasonable steps to notify people about matters such as who is collecting the information, why it is being collected, usual disclosures and privacy policy information. 

Privacy collection notice

The Australian Cervical Cancer Foundation collects the information in this form to respond to your school’s interest in the HPV and Me program, plan program delivery, provide relevant resources and communicate with your nominated school contact.

Please do not include student names, individual health information, vaccination records or other sensitive personal information in this form.

Information submitted through this form will be used by ACCF staff and authorised representatives for program planning, communication, reporting and evaluation purposes. ACCF will handle information in accordance with its privacy obligations and privacy policy. For privacy questions, please contact ACCF at: Helen.Boocock@accf.org.au.

I confirm that I am authorised to submit this registration of interest on behalf of the organisation.
I understand that this form should not include student names, student health information or vaccination records.
I understand ACCF may use the information provided to contact the organisation about the HPV and Me program.
Section 5: Can we contact you and feedback
We'd love to work with you to improve our resources. Would we be able to contact you for feedback please?
Would you like to receive updates about ACCF school resources and cervical cancer prevention education?

Australian Cervical Cancer Foundation - ABN 14 128 546 850
PO BOX 1008 Fortitude Valley Qld 4006