APPLICATION FOR MEMBERSHIP

Next review date: 1/07/2019 / Version number: 4.0 / Page 1 of 3

Senses Australia

Senses Australia is a leading not for profit organisation in Western Australia, providing services to people with disabilities. Senses Australia is one of the oldest charities in Western Australia turning 120 years old in 2015.

Senses Australia is a generic service provider, providing a large range of services to the person with the disability, their family, other health professionals and service providers and to teachers. Senses Australia’s services include

·  Support for an individual to live in the community

·  Therapy including physiotherapy, social work, occupational therapy, speech pathology and clinical psych

·  Information and resources

·  Advocacy and

·  A Consultative Services to other health professionals

Senses Australia’s head office is located at 11 Kitchener Ave, Burswood. 6100

Telephone 9473 5400

Fax 9473 5499

TTY 94735488

To Become a General Member of

Senses Australia

You need to be

1.  an individual over 18 years of age and not an employee of Senses Australia; or

2.  the nominated representative of a body corporate

You must

3.  Complete this application form

4.  Pay the annual subscription of $10 and

5.  Have you application approved by the Board.

Annual Membership is from 1st July to 30th June and you must remain financial to remain a Member

Please post or email this completed form to Senses Australia with your membership fee. You will be advised of your membership status following the next meeting of the Board.

PO Box 143

Burswood WA 6100

PLEASE ONLY COMPLETE ONE APPLICATION.

EITHER

I wish to apply for general membership of Senses Australia as an individual. I am over 18 years of age and not an employee of Senses Australia

Name: ______

Address: ______

Telephone / TTY: ______

Fax: ______

E-Mail: ______

Signed ______

My focus as a member is: (Please select þ)

r Client of Senses r Supporter of Senses r Service Provider

r Family member/advocate of a client of Senses

r Other (Please specify) ______

Alternative format required for publications/communication:

r Braille r Large Print r Audio Tape

Please debit the following card. (Sorry - no AMEX or Diners facilities)

r MasterCard r BankCard r Visa

Card No: ______.

Expiry Date: ______/ ______Amount $10.00

Cardholder’s Name: ______

Cardholder’s Signature: ______
OR

I wish to apply for general membership of Senses Australia as the representative of a Body Corporate. I am over 18 years of age and not an employee of Senses Australia

Name of individual: ______

Name of Body Corporate: ______

Address: ______

Telephone / TTY: ______

Fax:

______

E-Mail: ______

Signed by individual ______

Signed by the Responsible Person of the Body Corporate

______

My focus as a member is:

______

______

______

______

Please debit the following card. (Sorry - no AMEX or Diners facilities)

r MasterCard r BankCard r Visa

Card No: ______.

Expiry Date: ______/ ______Amount $10.00

Cardholder’s Name: ______

Cardholder’s Signature: ______

Next review date: 1/07/2019 / Version number: 4.0 / Page 1 of 3