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ABN 00 215 270 030 Last updated 01/06/2010 |
Disabled Surfers Association of Australia Incorporated Membership Application Form |
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Membership Branch: Central Coast Far North Coast Gold Coast Hastings Hunter Mid North Coast South Australia South Coast Sunshine Coast Sydney Victoria WA -South Coast WA - Perth New Zealand |
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DSA Membership Type: |
New Membership |
Renew Membership |
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Membership Details Of: |
Participant | Volunteer | Carer | Supporter |
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Name:
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Street Number:
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Address:
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Suburb:
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City:
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State:
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Country:
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Postcode:
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| Home Phone: | Mobile Phone: | Work: |
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E-mail Address:
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Date of Birth:
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Type of Surf Craft (if any):
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Type of Disability:
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Permission to Attend: |
Parent |
Guardian | Not Required |
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Signature: |
Contact Number: |
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Doctors Permission: |
Yes | No | Not Required |
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Signature: |
Contact Number: |
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NOTE: Please enclose doctors certificate if disability is not apparent. NOTE: "DSA T-Shirt" is not included in the Standard Membership COST: "DSA T-Shirt" is $10.00 + $5.00 (postage & handling) = $15 T-Shirt Size: XS S M L XL XXL XXXL XXXXL |
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$20 Membership |
$35 Membership + T-shirt $30 Membership + T-Shirt - no post |
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Date: |
Signature: |
| NOTE: If the person is under 18 years of age, a Parent or Guardian must sign on his/her behalf. | |
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Completed Forms - Together With Monies - Are To Be Made Payable To: Disabled Surfers Association Inc. Postal Address: PO Box 345, THE ENTRANCE, NSW, 2261 |
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