Application for Membership

Member Information
Title (Mr./Mrs./Miss/Ms.): / Date of birth:
Full Name:
Address:
Town/ Suburb / Postcode:
Phone: / (H) / (W) / (Mobile)
Email:
Gender: / c Male c Female

This application form consists of two pages. Please read and complete both pages

Injury
Spinal Cord Injury Level / ASIA classification / Date of injury / Place of injury (Town/City)
Injury Cause
Work
Crush
Disease Related / Motor Vehicle - Car
Motor Bike
Motor Vehicle - Other / Diving
Fall
Post-Surgery / Sport
Tree Felling
Water Accident / Other - specify
______
Other Types Disabilities
Acquired Brain Injury
Cerebral Palsy
Friedreich’s Ataxia / Mental Disorder
Motor Neuron Disease
Multiple Sclerosis / Muscular Atrophy
Muscular Dystrophy
Other - specify ______/ Post-Polio Syndrome
Spina Bifida
Transverse Myelitis
Congenital
Culture & Communication
Country of Birth:
Indigenous Status: / Aboriginal / Aboriginal and Torres Strait Islander
Torres Strait Islander / Not Aboriginal or Torres Strait Islander
What is the main language spoken at home?
English / Other, please specify ______
Employment
Employed / Unemployed
(seeking employment) / Not looking for work / Retired
Previous/ current Profession (Trade / Skill):
______/ Hobbies or interests:
______
Brisbane / Townsville / Cairns
Tel 07 3391 2044 109 Logan Rd Woolloongabba Q 4102 / Tel 07 4755 1755 488 Ross River Rd, Townsville Q 4824 / Tel 07 4799 1111 Unit 1, 325- 327
Fax 07 3391 2088 PO Box 5651 West End Qld 4101 / Fax 07 4723 8677 PO Box 618, Aitkenvale BC Qld 4814 / Fax 07 4723 8677 Sheridan St Nth Cairns Qld 4870
Email / Email / PO Box 452 Nth Cairns Qld 4870
ARBN 052 413 528 / www.spinal.com.au / ABN 39 293 063 049
Types of membership and Fees: (Please tick the type of membership for which you are applying)
Ordinary member: Annual subscription fee $15, concession $10*
To be eligible you must be at least 18 years of age and reside in Queensland, and you must have a primary disability that is due to an acquired spinal cord injury, either by accident or disease (which includes a person who has had polio).
Associate member: Annual subscription fee $15, concession $10*
Any person is eligible, however, associate members do not have the right to vote. Do you have a disability?
c No c Yes If yes, please specify:______
Complimentary 3 year membership: Spinal Injuries Unit patient
Life member: (One-off subscription fee, $500)

Annual membership is renewable by 30 June each year

*Concession rates are available to anyone issued with a government entitlement card.

Public liability insurance

Spinal Injuries Association Inc. has public liability insurance of $20,000,000.

Privacy statement

Spinal Injuries Association Inc. complies with the Australian Privacy Principles contained within the Privacy Act 1988. We have asked you for your personal information so we may identify specific needs and characteristics of members so we can provide appropriate Association membership services. Where specific information is not provided it may limit the ability of the Association to deliver relevant member services. The information you have provided will be kept strictly confidential and not disclosed to any third party organisation by any means unless consent is obtained. If you would like to access a copy of the Association’s Privacy Policy, please contact us. Should you wish to raise a concern about the privacy of your personal information please contact the Association.

I confirm the information supplied in this application is true and correct. I hereby apply for membership and agree to abide by the rules of the Association.
This form must be signed by or at the direction of the applicant (or by the applicant’s guardian if the applicant is less than 18 years of age).
Applicant Signature: / Date:
If signed by someone other than the applicant please print name / Name:
METHOD OF PAYMENT
Cheque (please make cheque payable to “Spinal Injuries Association” / Money order /
Visa / MasterCard

Transaction processed (office Use): ______/ / .

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Credit Card Number: / Expiry Date:
Card Holder’s Name: / CCV *
Amount Payable: / * 3 digit code found on back of credit card
Cardholder Signature:
Version: 11
Issued Date: 28082013
Document No: 100243
Printed copies are uncontrolled. / Page 2 of 2