Membership with Spinal Life Australia « Spinal Life Australia

Section A - Personal information
Name*
Title First Last
Email*
Date of birth*
Gender*
Mobile*
Phone (Home)
Phone (Work)
Address*
Street Address Address Line 2 Town/Suburb State Postcode Country
Section B - Types of membership and fees
Membership Type*
- Ordinary member ($15/year)
  Any individual not less than 18 years of age at the date of the application may apply for ordinary membership of the Company. Please complete section C.
- Ordinary member (concession) ($10/year)
- Junior Ordinary member ($15/year)
  To be eligible you must be less than 18 years of age at the date of application, and you must have a primary disability that is due to an acquired spinal cord injury, either by accident or disease (which includes a person who has had polio). Please complete section C.
- Junior Ordinary member (concession) ($10/year)
- Life member (one-off subscription fee $500)
Annual membership is renewable by 30 June each year.

*Concession rates are available to anyone who is in receipt of a Commonwealth Government pension card.
Sction C - Personal and health information
Spinal cord injury level
Injury cause
- Work
- Motor vehicle
- Fall
- Water accident
- Other (please specify)
Other injury cause?
Other types of disabilities
- Post-Polio Syndrome
- Transverse Myelitis
- Other (please specify)
Please specify other disability
Section D - Terms, conditions and privacy
To view our full Privacy and Confidentiality policy, and terms and conditions of your membership, please click here.
Section E - Payment
Method of payment?*
- Cheque (payable to "Spinal Life Australia Ltd"
- Money order
- Visa
- MasterCard
Total due
$ 0.00
Credit Card*

MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Apply to become a member

Section A - Personal information

Section B - Types of membership and fees

Sction C - Personal and health information

Section D - Terms, conditions and privacy

Section E - Payment