Membership Form

Build a Better Me - Arthritis , Pain Support & Me/CFS ACT Membership Form

First name *

Last name *

Postal Address *

Suburb/Town *

State/Territory *

Postcode *

Date of birth *

Gender *

Phone number *

Phone number (w)

Mobile

Email address *

Additional Family Member - One

First name (additional member 1)

Last name (additional member 1)

Relationship (additional member 1)

Date of birth (additional member 1)

Email address (additional member 1)

Phone number (additional member 1)

Additional Family Member - Two

First name (additional member 2)

Last name (additional member 2)

Relationship (additional member 2)

Date of birth (additional member 2)

Email address (additional member 2)

Phone number (additional member 2)

Which of the following applies to you?

Osteoarthritis

Autoimmune Arthritis

Chronic Pain (not Arthritis)

NDIS Client

Myalgic Encephalomylitis

Non - ME/CFS

DVA Client

Former Pain Support Member

Former ME/CFS Society Member

Other Autoimmune Disease

Gout

No particular condition

Membership Subscriptions

Individual ($67)

Previous Pain Support ACT Member Only ($35)

Concession ($49)

Previous ME/CFS Society Members Only ($35)

Family ($103)

Concession Family ($77)

*NDIS clients who are paying full NDIS rates do not pay membership

Donation (over $2 is tax deductible)

Warm Water Exercise Tickets

Number of single tickets (at $5.90 per ticket)

Number of 20 ticket booklets (at $115 per booklet)

Number of 40 ticket booklets (at $220 per booklet)

Before commencing exercise and hydrotherapy classes each person must complete and exercise screening and may need additional clearance from their GP.

Please complete this form and return to by pressing the submit button at the bottom of the page. Our reception staff will telephone you so that you can make payment. Alternatively, payment for memberships can be made in person at our Bruce or Pearce office (170 Haydon Drive Bruce (9-5 Mon-Fri) or Building 1, 1 Collette Place Pearce - 9.30 - 2.30 Mon-Fri) or by posting a printed copy of this form to PO BOX 908 Belconnen ACT 2616)