Membership

Neerim Health Membership

Type of Application:(Required)

Renewing Member

New Member

Type of Membership:(Required)

My/our membership of Neerim Health Inc. shows a commitment to our district’s essential community health asset. I/we confirm my/our membership of the Neerim Health Inc. Association for the period to 1 July to 30th June.

Membership is non refundable and only available to persons aged 18 or above(Required)

I am 18 years or older

As part of your membership, Neerim Health will email you Association News, Notices and Renewals. If you prefer to opt-out of emails, and receive hard copy correspondence in the mail, please tick the box below

I would like to receive hard copy correspondence

Members Name:(Required)

Prefix First Last

Member 1:(Required)

Prefix First Last

Member 2:(Required)

Prefix First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City or Suburb State Post Code

Single(Required)

Price:

Couple(Required)

Price:

Single - 5 year(Required)

Price:

Couple - 5 year(Required)

Price:

Single - 10 year(Required)

Price:

Couple - 10 year(Required)

Price:

Would you also like to make a donation?

Please also consider making a donation - Donations over $2 are tax deductible. Nominate your donation amount above.

Total

Payment Method(Required)

Secure Credit Card Payment

Direct Deposit

Cash

Credit Card(Required)

Bank: Commonwealth Bank of Australia Account Name: Neerim Health BSB: 063 532 Acct No: 10644625

Reference:

Please confirm deposit via email to info@neerimhealth.org.au Subject: Your full name - Membership

Please pay at reception - DO NOT send cash via post.

Signature(Required)

Signature (Member 2)(Required)

Neerim Health Membership

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