Become A Member "*" indicates required fields1Contact Details2Personal Details3Membership4Payment5SubmitContact DetailsName* First Last Email* PhonePersonal DetailsDate of Birth* Day Month YearEthnicity*AfricanAmericanBangladeshChineseCook IslandsDon't KnowDutchEnglishFijianIndianLatin AmericanMaoriMiddle EasternNineNiuenNZ EuropeanOther AsianOther EthnicityOther EuropeanOther Pacific PeoplesPacific IslanderPhillipinesSamoanScottishSouth AfricanSouth East AsianSwedishTaiwanTokelauanTonganTuvulauanVietnamWest IndiesAddress* Street Address Suburb Town / City Post Code Alternative Contact NameAlternative Contact NumberMembership DetailsHow did you hear about ME Respite?*Which of our programs are you interested in?* Meals Delivery Saver Household and Personal Goods Support Groups Craft Groups Well Being Check Is There Any Other Support You Require?Other Support you requireMembership Type* Services Recipient (subscription) Services Hardship Financial Supporter (subscription) SupporterCost is $4.30 per month, giving you access to all of ME Respite’s services and support offerings.For those that are unable to afford the membership fee. Access to all of ME Respite’s services and support offerings free of charge.Thank you. For a financial contribution that you are comfortable with you get access to the ME Respite Newsletter and invitations to ME Respite Events.For those wishing to show their support for ME Respite’s activities and vision. You get access to the ME Respite Newsletter and invitations to ME Respite Events.Reason for becoming a member?* I have ME/CFS I am a carer OtherReason for supporting ME Respite?* I have ME/CFS I am a carer I know someone with ME/CFS I just want to show my support OtherPaymentService Recipient Price: Membership will be charged to your credit card monthlyFinancial Supporter*Enter an amount you are comfortable to pay monthly for your membership Credit Card*Card Details Cardholder Name Disclaimer: The information shared on this form will be kept confidential within the Trust. We do not share details with third parties. You can at any time withdraw your membership and request the changing or deletion of your personal details. ME RESPITE will at all times comply with the Privacy Act 1993 and the Health Information Privacy Code 1994. I also understand that I will be welcomed to the trusts mailing list but that I can unsubscribe at any time.All information is accurate*I heareby affirm that all information given by me in this application is true and correct and give permission to Rest Assured Respite Trust to hold it securely until I ask for it to be removed. I agreeNewsletter*I understand that I will be welcomed to the trusts mailing list but that I can unsubscribe at any time. I understandPhoneThis field is for validation purposes and should be left unchanged.
