Canberra & Queanbeyan ADD Support Group Inc

PO Box 717

MAWSON  ACT 2607

Canberra & Queanbeyan ADD Support Group Inc

PO Box 717, MAWSON  ACT  2607

Application for Membership

Individuals / Families: Concession card    $15.00 (concession card must be shown)

Individuals / Families  General              $25.00

Organisation:  Non-profit                     $35.00

Organisation: General                         $50.00

Please tick    New member________        or Re-joining  __________

Title:        Ms/Mrs/Miss/Mr

Surname: ____________________________________________________

 Given:     ____________ _______________________________________

Organisation: (if applicable): _____________________________________

Address: ____________________________________________________

Suburb_____________________________________    Postcode: _______

PHONE: Home:   __________________        Mobile___________________

 Email:  _____________________________________________________

All donations over $2.00 are Tax Deductible.  A Tax Invoice will be posted.

My cheque / postal note / cash: …………………………… is enclosed: 

Please make cheque payable to the “Canberra & Queanbeyan A.D.D. Support Group Inc”

Membership fee      $………. Donation: $………. Total: $……….

Visa / MasterCard / Bankcard  - please circle

 __ __ __ __ /__ __ __ __ /__ __ __ __/ __ __ __ __ Expiry __ __ /__ __

 Name on card ____________________      ____________________________

                         (Please print)                                      Signature

In order to gain an idea of the composition of our membership, we would appreciate it if you could indicate below your area (s) of involvement / interest in A.D.D. Please tick appropriate box (s).

 [ ] Child A.D.D. Please specify age( s) …… …… 

 [ ] Adult A.D.D.                                        

 [ ] Adolescent A.D.D please specify age( s)       

 [ ] Teacher …… … … … … … … … … … … … …        

 [ ] Other … … … … … … … … … … … …

 [ ] Willing to participate in part of a survey, if our Support Group is required to gather information for funding, statistics etc confidentially assured.

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 Office Use Only

[           ] Membership No      [           ] Membership Card     [          ] ACCESS updated    

[           ] Tax Invoice           [           ] Membership Letter   [          ] Email address added