MEMERSHIP FORMMembership Categories Before completing the Membership Form, please read the...
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Office Use only Receipt Banked Donations Database Updated Member Pack Receipt Posted MEMBERSHIP FORM Before compleng, please read the informaon on the back carefully Date _____________ Membership category New Annual Member Renewing Member Life Member Title _____________ First Name ____________________________ Surname ________________________________ Date of Birth* / / Date Diagnosed* / / *only applicable to a person with Parkinson’s Address ____________________________________________________________________________________________ _______________________________________________________________________ Postcode _____________________ Phone __________________________________ Email ____________________________________________________ Are you a health professional? If yes, please indicate your area of pracce _________________________________________ ADDITIONAL MEMBERS LIVING AT THE SAME ADDRESS Associate Member Annual Co-Member Life Co-Member Title _____________ First Name ____________________________ Surname ________________________________ Date of Birth* / / Date Diagnosed* / / *only applicable to a person with Parkinson’s Payment Details Payment Type: Cheque** Cash Bank Deposit **(made payable to Parkinson’s WA) Visa Mastercard Card Number / / / Expiry Date / Name on Card Signature Direct Credit Details: Parkinson’s WA Inc Commonwealth Bank BSB: 066-125 Acc No: 00906938 Membership Fee(s) $ Donaon $ Total Payment $ HBF Provider No. B5230PRE HBF Code PRH4 HBA Provider No. 9938291L Parkinson’s Western Australia Inc. The Niche, 11 Aberdare Road, NEDLANDS WA 6009 T: 6457 7373 E: [email protected] W: www.parkinsonswa.org.au ABN: 88404 764 099 In accordance with our Privacy Policy, all Membership informaon is treated confidenally. S:\Membership Documents\2016\Membership Form 28-Apr-16
Transcript of MEMERSHIP FORMMembership Categories Before completing the Membership Form, please read the...
Office Use only
Receipt
Banked
Donations
Database Updated
Member Pack
Receipt Posted
MEMBERSHIP FORM Before completing, please read the information on the back carefully
Date _____________ Membership category New Annual Member Renewing Member Life Member
Title _____________ First Name ____________________________ Surname ________________________________
Date of Birth* / / Date Diagnosed* / / *only applicable to a person with Parkinson’s
Address ____________________________________________________________________________________________
_______________________________________________________________________ Postcode _____________________ Phone __________________________________ Email ____________________________________________________ Are you a health professional? If yes, please indicate your area of practice _________________________________________
ADDITIONAL MEMBERS LIVING AT THE SAME ADDRESS
Associate Member Annual Co-Member Life Co-Member Title _____________ First Name ____________________________ Surname ________________________________
Date of Birth* / / Date Diagnosed* / / *only applicable to a person with Parkinson’s
Payment Details Payment Type: Cheque** Cash Bank Deposit **(made payable to Parkinson’s WA)
Visa Mastercard Card Number / / / Expiry Date / Name on Card Signature
Direct Credit Details: Parkinson’s WA Inc Commonwealth Bank BSB: 066-125 Acc No: 00906938
Membership Fee(s) $
Donation $
Total Payment $
HBF Provider No. B5230PRE HBF Code PRH4 HBA Provider No. 9938291L
Parkinson’s Western Australia Inc. The Niche, 11 Aberdare Road, NEDLANDS WA 6009
T: 6457 7373 E: [email protected] W: www.parkinsonswa.org.au ABN: 88404 764 099
In accordance with our Privacy Policy, all Membership information is treated confidentially. S:\Membership Documents\2016\Membership Form 28-Apr-16
Parkinson’s Western Australia Inc
Membership Categories
Before completing the Membership Form, please read the information below defining our Membership categories
A Annual Membership $36
This category is available to any person who pays the full annual membership fee. One copy of the newsletter will be delivered to the Annual Member and reduced fees apply for attendance at seminars.
B Annual Co-Membership $18
This category is available to a person provided that one person in the household has paid a full annual membership and where both persons reside at the same address. One copy of the newsletter will be delivered to the Annual Member and reduced fees apply for attendance at seminars.
C Associate Membership Free
This category is available to a person provided that one person in the household has paid a full annual or life membership fee and where both persons reside at the same address. Associate members will not have voting rights at the AGM. One copy of the newsletter will be delivered to the Annual Member and reduced fees apply for attendance at seminars.
D Life Membership $330
This category is available to a person who pays the full life membership fee. One copy of the newsletter will be delivered to the Life Member and reduced fees apply for attendance at seminars.
E Life Co-Membership $165
This category is available to a person provided that one person in the household has paid a full life membership and where both persons reside at the same address. One copy of the newsletter will be delivered to the Life Member and reduced fees apply for attendance at seminars.
Please complete the following: To assist the Parkinson’s WA with further promoting our services, could you please let us know where you heard about the Association: GP Parkinson’s Nurse Specialist Neurologist Parkinson’s Clinic Gerontologist Radio Allied Health Professional Friend eg. Physiotherapist, Speech Therapist Newspaper PWA Website Please name the newspaper/magazine or Radio Station: ________________________________________________
