Please Complete This Form to Register Your Group As a BCNA Member Group

BCNA Member Group Registration Form

Please complete this form to register your group as a BCNA Member Group.

To be eligible for registration your group must provide peer support or be open to supporting women/families who have been affected by breast cancer (eg. breast cancer specific groups, generic cancer groups or groups with a specific focus such as lymphoedema)

All registrations will be considered and in instances where groups are not eligible for registration we will contact you to discuss other ways to be involved with BCNA.

Group Name: / Date: / /
Suburb/Region: / State:
Your Members
Where do your members live?
Metro Regional/Rural Remote
Who do you welcome into your group?
BREAST CANCER ONLY
Anyone who has had any breast cancer diagnosis
Specifically for those living with a secondary/metastaticbreast cancer diagnosis
BREAST CANCER PLUS
Anyone with any cancer diagnosis Only those living with a secondary/metastatic cancer
Family/friends General public Other (specify):
Approximate number of members:
Your group activities
Tell us a bit about what your group does
Casual Meetings
Fundraising / Social Gathering
Advocacy / Formal Meeting
Speakers
Exercise eg. Dragon boating (specify) / Other (specify)
When and where do you meet?
When: (eg. 3rd Tuesday of each month)
Where: (eg. Box Hill RSL Club)
How would you describe your group?
Example: Our group meets monthly to share an afternoon cuppa, give each other support and listen to a speaker.

Member Group Contact

We require a primary contact for your group. This will be the person with whom BCNA will communicate regularly. It is expected that any communication will then be forwarded to group members. It is preferable the primary contact be a breast cancer survivor.

Please also note that unless otherwise requested names and contact phone/email will be made available on our online network for those wishing to contact your group.

Primary Contact
Name:
Breast cancer survivor Health professional Group facillitator Other (specify)
Address
Suburb / State / P/code
Email / Home
Moblie: / Work
Permission to promote group contact: Name Email Mobile Home Work
Secondary Contact
Name:
Breast cancer survivor Health professional Group facillitator Other (specify)
Address
Suburb / State / P/code
Email / Home
Moblie: / Work
Permission to promote group contact: Name Email Mobile Home Work

Please save your completed form to your computer then attach to an email to . Alternatively you can fax or post the form attention to me using the details below.

Thank you for taking the time to complete this form and we will be in contact to discuss your registration.

Janelle Woods

Member Groups Coordinator

Breast Cancer Network Australia

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