EmailMe Form - RENEWAL OF MEMBERSHIP FORM

Member's Name *

Prefix First Last

Date of Birth *

Current Occupation

Business Name (if applicable)

(Phone) Mobile *

Phone (Landline)

Email Address *

Confirm

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Which of the following describes you best? *

A person with Primary Lymphoedema

A person with Secondary Lymphoedema

A Relative or Friend of a person with Lymphoedema

A Professional Service Provider for Lymphoedema patients

Please select a Membership Category (Fee renewable annually) *

General Membership - $40.00

General Membership (Concessional) - $30.00

Health Professional Membership - $99.00

PLEASE NOTE: As part of yearly membership fee Professional Members receive a FREE listing in our Lymphoedema Services Directory.

In addition to Renewing my Membership I also wish to make a donation of the following amount.

YOUR PREFERRED METHOD OF PAYMENT *

Credit Card - Please send me the Stripe Payment link.

Direct Deposit - I have deposited to the nominated bank account below using my First and Last Name as the reference

NAME: Lymphoedema Association of Qld Inc.
BANK: Westpac
BSB: 034 272
ACC: 12 5179
REFERENCE: Membership and {Your Last Name}

Additional Information To Note:

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