Membership Form

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

To become a member of Build A Better ME - Arthritis, Pain Support and ME/CFS ACT please 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 *

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)

Does any of the following funding apply to you?

DVA Client

NDIS Client

Aged Care

EPC (Medicare)

Do any of the following conditions apply to you?

Autoimmune Arthritis

Chronic Pain (not Arthritis)

Former Pain Support Member

Former ME/CFS Society Member

Gout

JIA

ME/CFS

No particular condition

Osteoarthritis

Other Autoimmune Disease

Membership Subscriptions

Annual Membership ($49)

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

Previous Pain Support ACT Member Only ($35)

Previous ME/CFS Society Members Only ($35)

ME/CFS Free Membership (support groups only) $0

Donation (over $2 is tax deductible)

Warm Water Exercise Tickets

Number of single tickets (at $6.00 per ticket)

Number of 20 ticket booklets (at $117 per booklet)

Number of 40 ticket booklets (at $224 per booklet)

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/

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