Membership Neerim Health Service Type of Application:(Required) Renewing Member New Member Type of Membership:(Required)-- Please Choose Membership Type --Single ($25 per year)Couple ($40 per year)Single - 5 year ($125 every 5 years)Couple - 5 year ($200 every 5 years)Single - 10 year ($250 every 10 years)Couple - 10 year ($400 every 10 years)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) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Member 1:(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Member 2:(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. 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)Feed Required: To use the Stripe field, please create a Stripe feed for this form. 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 - MembershipPlease pay at reception - DO NOT send cash via post.Signature(Required)Signature (Member 2)(Required)
