Junior concessional membership renewal form To renew your membership, fill out the form below. Don’t forget, your annual membership is renewable by 30 June each year. Section A - Personal informationName* Mr.Mrs.MissMs. Title First Last Email Membership IDThis field is optionalHave your contact details changed?*NoYesIf yes, please enter your new contact details below.Section B - Types of membership and feesMembership type*Junior Ordinary (concession) member ($10/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).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.Section C - DonationWould you like to make a donation today?*YesNoDonation amount*How much would you like to donate? Section D - PaymentMethod of payment*VisaMasterCardTotal due $ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Section E - Your privacyDisclaimer – Spinal Life Australia is collecting the information on this form for membership purposes. Only authorised employees of the organisation have access to this information. Your personal information will not be disclosed to any other third party without your consent, unless authorised or required by law. A full version of the Privacy Policy can be accessed by clicking here.
