Membership Application Form

Membership Application Form

Each paid membership is a single membership for the applicant aged 18+
Name *

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State

Post Code Country
Contact Phone Number *
Email *
Interest In Joining. I am: *

an adult with a CCD a parent of a child/adult with a CCD another relative, partner or friend of someone with a CCD a professional working with people with CCD a person or organisation interested in CCD
MEMBERSHIP OPTIONS

AusDoCC Inc memberships are available for adults aged 18 and above. Each membership is a single membership for the person signing up. Details will be collected about yourself if you are the person with the CCD or about relevant children or adults with a CCD
Membership Option. Once Off Joining Fee. Membership is ongoing after the Joining Fee has been Paid ( If applicable) *

FREE Single Membership for adults with a CCD Single Adult (18+) $20 Professional Membership (Individual or organisation) $120
Details of Child or Adult with a CCD
Child or Adult with a CCD
Child or Adult 1 with a CCD *

First Name Last Name
Date of Birth *

Month Day Year
Gender *
Relationship to you *
Is this person with a DCC your child, adult child, yourself, another relation or no relation?
Condition *

Complete ACC Partial ACC Thin Corpus Callosum (hypoplasia) Thick Corpus Callosum
Is the CCD associated with other conditions *

Yes No
If yes, please give details of other conditions
Do you have another child or adult with a CCD to add? *

Yes No
2nd Child or Adult with a DCC
Child or Adult 2 with a DCC

First Name Last Name
Date of Birth

Month Day Year
Gender
Relationship to you
Is this person with a DCC your child, adult child, yourself, another relation or no relation?
Condition

Full ACC Partial ACC Thin Corpus Callosum Thick corpus callosum
Is DCC associated with other conditions

Yes No
Details of other conditions
Do you have more people to add?

Yes No
Child or Adult 3
Child or Adult 3 with a DCC

First Name Last Name
Date of Birth

Month Day Year
Gender
Relationship to you
Is this person with a DCC your child, adult child, yourself, another relation or no relation?
Condition

Full ACC Partial ACC Thin Corpus Callosum
Is DCC associated with other conditions

Yes No
Details of other conditions

Contact and Privacy
The information collected in this form is for the use of AusDoCC Inc. All information is confidential and will not be shared with any third party without prior consent. AusDocc Inc uses email to share relevant information, resources and newsletters with members, including information about upcoming events and opportunities. The Privacy Act 1988 allows applicants to access and amend their personal information at any time. Please contact info@ausdocc.org.au for a copy of the AusDoCC Privacy Policy.
Declaration
By signing below, I desire to become a member of AusDoCC Inc. I agree to support the purposes and rules of AusDoCC and accept the terms and conditions of application for membership. I declare that all the information given on this form is true and correct.
Signature *
Optional Donation - All donations are tax deductible

Yes, I wish to help AusDoCC Inc. to support all those with a disorder of the corpus callosum and their families.
Donation Amount

$25 $50 $100
Method of Payment
Payment Method

Direct Bank Transfer (preferred method) Paypal
Direct Bank Transfer Details

Account Name: AUSDOCC INC

BSB: 013257

Account Number: 378800587

Please put your Full name as a reference
Once you submit this form with payment and your membership has been approved, you will receive a confirmation by post with a membership pack. Please do not hesitate to contact us if you have any questions or concerns.

Thank you for applying for membership with AusDoCC and supporting our work.

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should be Empty:

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Membership Application Form

Details of Child or Adult with a CCD

Contact and Privacy

Declaration

Method of Payment