Online Membership Application Form

Cancer Voices NSW
Online Electronic Membership Application Form

1. Group Membership

A	Member	Cancer consumer group	Cancer support group
B	Associate Member	Carers group	Professional body
		Health care institution
Other (please specify)

Organisation Details

Contact person		Position
Name of organisation
Postal Address

Suburb

City

State

Postcode

Phone (day)

(evening)

(mobile)

Fax

Website

Number of members in your organisation

2. Individual Membership (Associate)

Cancer survivor		Cancer patient
Family member		Carer
Health professional

Other (please specify)

Type of cancer experienced

Year(s) experienced

Personal Details

Title

First Name

Surname

Postal Address

Suburb

City

State

Postcode

Occupation

Phone (day)

(evening)

(mobile)

Fax

Male		Female
Age group
18-29		30-49
50-69		70+

3. What skills could you contribute to Cancer Voices?

Administrative			Communications and media		Representational
Fundraising			Policy development		Newsletter/website

Other (please specify)

4. Consumer training

The Cancer Consumer Advocacy Training course offers skills and confidence for cancer consumers interested in being consumer representatives or advocates on behalf of Cancer Voices NSW. It is held several times a year, for two days (Friday and Saturday) in metropolitan and regional centres. This is an initiative of Cancer Voices and is provided by The Cancer Council NSW. An expression of interest form for the course can be sent to you by contacting Meagan Lawson on 02 9334 1850 or via email - meaganl@nswcc.org.au

5. Donations

Cancer Voices NSW is entirely dependent on donations to operate. There is no fee to join, but we suggest a donation of $30 for groups and $10 for individuals. Any donation will help the VOICE to be heard. Please mail cheques or postal orders (Made payable to Cancer Voices NSW) with this application form and, if a receipt is required, please also enclose a stamped, self-addressed envelope. Tax deductible gift status is not available at this stage.

Contribution Amount: $

6. What issues would you like to flag as a Cancer Voices NSW member?

	Press this button once after completing the form. This will send the information you have typed in the boxes above to us by email.
	Click this button to clear all information from the form (use this only if you want to start again)