Membership Form

Arthritis , Pain Support & Emerge ACT Membership Form

To become a member of Arthritis, Pain Support and Emerge ACT p lease complete this form and return it by pressing the 'submit' button at the bottom of the page.

First name *

Last name *

Postal Address *

Suburb/Town *

State/Territory *

Postcode *

Date of birth *

Gender *

Mobile *

Phone number (h)

Phone number (w)

Email address *

DVA

NDIS

Age Care

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)

Membership subscriptions

Membership with Arthritis, Pain Support and ME/CFS ACT is valid for 12 months from the date of payment. Membership provides you with discounted visits with our allied health professionals, access to our wide range of exercise classes, hydrotherapy and regular newsletter.

Annual Membership ($49)

ME/CFS ACT (Online Group Membership) (Free)

Donation (over $2 is tax deductible): $________________________

I would like information on:

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

Details provided to us on this form will be used to create a membership profile for you, in our database. For information on our Privacy Policy please click on this link https://www.arthritisact.org.au/about-us/

Fees apply for all allied health services, prices for our services can be provided on request.

If you have any questions or would like assistance completing this form please contact our office on (02) 6251 2055.