APPLICATION FOR MEMBERSHIP Title
Given Names
Family Name
Preferred Name for Badge Sex M/F
Year of Birth
Address
Post Code
Suburb
Email Address
Home Phone
Mobile Phone
Previous Occupation(s)
Interests / Hobbies
1st Emergency Contact Name
Relationship
Home Phone
Mobile Phone
2nd Emergency Contact Name
Relationship
Home Phone
Mobile Phone
Emergency Doctor [To print on the back of the Member’s Badge]
Doctor’s Phone Number
If you are a current member of another U3A, please state which one
If you are interested in volunteering your skills and experience, and would like to contribute to the running of U3A Wheelers Hill, please place X in the box below the appropriate area Class Computer / Equipment Tutor Office Duties Committee Assistance Data Entry Maintenance
MEMBERSHIP FEE INFORMATION If pay by cheque, please make payable to U3A Wheelers Hill Membership Fee Single $50 Couple $80 ($40 + $40) Associate Single $35
Category Full Associate Tutor
Paid by Cash Cheque EFT BSB 013271 Acc No. 219979241
Paid
Date
$
U3A Wheelers Hill Inc., 1 Jacksons Road, Mulgrave VIC 3170 Website: http://www.u3awheelershill.com Email:
[email protected]