Name* First Last Are you of Aboriginal or Torres Strait Islander origin? Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Email* Address* Address line 1 Address Line 2 City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* DD slash MM slash YYYY Contact Number*Gender* Male Female Would you like to join any of ACA interest groups? Yes No Can we keep you updated with important news on your mobile? Yes No By selecting yes you are agreeing that ACA can send you SMS updates, which you can unsubscribe from at any time.Which University or College are you enrolled at?* Macquarie University Murdoch University RMIT University Central Queensland University - Mackay Central Queensland University - Brisbane Central Queensland University - Sydney Australian Chiropractic College - Adelaide Can we check your enrolment status with your University? Yes No By selecting yes you are agreeing that ACA can contact your University to check you are a current student, which you can unsubscribe from at any time.Current year of study? Year 1 Year 2 Year 3 Graduate Entry (Bachelor in non-chiropractic related field) Year 4/Yr 1 MSc Year 5/Yr 2 MSc Current year of study :: full time equivalentYear you commenced your studies?* eg. 2011Anticipated year of graduation?* The year your studies will end (not necessarily the year you attend a graduation ceremony.What prompted you to become a member? Select All some of my Uni friends are members information I was given by a ACA representative information I was given by a student representative to receive regular updates about the chiropractic profession to access some of the services/benefits ACA offers Which are the KEY services/benefits you are planning to use? Select All email updates educational events chiropractic information and materials The Australian Chiropractor magazine access to a network of chiropractors Do you want to participate in the FREE ACA Student Master Policy from Guild for Liability Insurance?* Yes No To your knowledge, has there been or is there now pending any Claim, action, complaint, inquiry, disciplinary proceedings or other litigation against You?* Yes No In the last 5 years, have you been convicted of a criminal offence (other than a minor traffic infringement)?* Yes No After inquiry, are you aware of any fact, situation or circumstance that may give rise to a claim, inquiry, disciplinary proceedings or other litigation against You?* Yes No If you have answered 'Yes' to any of the above questions, please provide further information below as your application will be referred to Guild Insurance Limited for an individual review. You may be contacted for additional information. Please note that your membership information will be provided to the insurer.Duty of DisclosureBefore you become insured under the ACA Student master Policy, the ACA has a duty of disclosure under the Insurance Contracts Act 1984. In order for the ACA to comply with this duty, you must disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer's decision whether to accept the risk of insurance and, if so, on what terms. The duty of disclosure also applies before cover is renewed, varied or reinstated. The duty does not, however, require disclosure of a matter 1) that diminishes the risk to be undertaken by the insurer; 2) as to which the duty of disclosure is waived by the insurer; 3) that the insurer knows, or in the ordinary course of its business, ought to know; 4) that is common knowledge. Non-DisclosureIf the duty of disclosure is not complied with, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If the non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. I declare the answers and information given in this declaration are true and correct and I have not withheld any information likely to affect the terms and conditions of the insurance provided under the ACA Student Master Policy.* Yes No I agree that upon acceptance of this declaration the insurance will be subject to the terms, conditions, exclusions and provisions of the ACA Student master Policy underwritten by Guild Insurance Limited (GIL)* Yes No I authorise GIL to make any necessary checks of other insurers to confirm the information I have supplied in this Declaration* Yes No I consent to the collection, use and disclosure of your personal information to evaluate, effect, manage and administer your insurance cover provided to you by GIL under the ACA Student master Policy. This applies to personal information provided previously, currently and in the future.* Yes No Your policy is subject to terms, conditions and exclusions. It is important that you review the Policy Wording to understand what you are covered for in the event of a claim and ensure that the level of cover is suitable for your needs. Please click the links below to access the Policy Schedule and the Students Liabilities Insurance (master policy wording). Policy Schedule Policy WordingConsent* I have read and agree to the Privacy Statement.Guild Privacy Statement If you do not provide the above information GIL may not be able to evaluate, effect, manage or administer your insurance cover. GIL will ensure that your personal information is accurate, up-to-date and complete. You may access personal information GIL holds about you by contacting GIL. If you would like to make a complaint about how GIL has handled your personal information please contact GIL and speak to one of GIL's staff who will assist you. GIL's Privacy Policy contains further information on access, correction and complaints handling procedures and can be accessed online at http://www.guildinsurance.com.au/customer-centre/usefulinformation Alternatively, you can write to GIL at Locked Bag 7, Hawthorn VIC 3122 or contact GIL on 1800 810 213 during office hours and GIL will arrange for a copy of the Privacy Policy to be provided to you.CAPTCHANameThis field is for validation purposes and should be left unchanged.