Name(Required) First Last Age(Required)Phone number(Required)Email Address(Required) Street Address Address Line 2 City Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Name of your chiropractor(Required) First Last Your chiropractor's phone number(Required)Please provide a quote which we can include in a media release to express your support for Spinal Health Week and chiropractic care (max two sentences).(Required)EXAMPLE: “Spinal Health Week is a great initiative by the Australian Chiropractors Association designed to shine a spotlight on spinal health conditions impacting millions of Australians like me. I had been experiencing acute back pain since I was in my early twenties which limited my ability to focus, made me irritable and unable to participate in the activities I love. After years of using over the counter or prescription medication, my chiropractor now provides me with an effective drug-free treatment which has not just helped relieve my headaches, importantly it’s given me back control of my life.”How long have you been experiencing back pain?(Required)How frequently do you experience back pain?(Required)What impact has back pain had on your life? Does it impact you at home, work and recreationally?(Required)Describe the feeling of your back pain?(Required)How long have you been seeing your chiropractor?(Required)What impact has chiropractic care had on your back pain?(Required)Provide your personal story (max 500 words)(Required)Please tell us your personal experience which we may use to put you forward for a media interview. It doesn’t have to be long and you don’t have to mention anything you don’t feel comfortable sharing. Your story can be a couple of paragraphs up to a maximum of 500 words. Please supply a current hi-resolution photograph of yourself if available (ensure the photographs are a minimum of 1MB). Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 3 MB, Max. files: 3. Consent(Required) I agree to participate in the Spinal Health Week publicity campaign.I agree to the Australian Chiropractors Association (ACA) and its representative Insight Communications to put me forward for media interviews for the purposes of raising awareness of Spinal Health Week and the ACA.
