Membership Application Form

Membership Application Form
I am applying for:
Name

First NameLast Name
Date of Birth:

DayMonthYear
Date
Other name/s known by:
Residential Address:
Postal Address:
Leave blank if same as above
Mobile:
Email:
example@example.com
Occupation
What service do your child/children attend
If you are applying for Staff Membership which service are you employed at:
As an Adventure Patch employee I am employed:
PARENT MEMBERS
I would prefer my partner/other family member to be a member of Adventure Patch
The parent that is registered as the CCS recipient is eligible for membership. If you would like a different parent to hold membership, please note the parent name and reason for the request below.

This request is subject to acceptance by Adventure Patch
Name

First NameLast Name
Reason for request:
Reason For Request:
Member Declaration
By submitting, I hereby apply for Membership of Adventure Patch Ltd and agree to accept the objects of the company and terms and conditions of membership as amended from time to time.
Date

DayMonthYear
Date
Adventure Patch (ABN 21 707 156 941) (ACN 636 599 990)

PO Box 64, Blackmans Bay TAS 7052 P: (03) 6229 4914

E: admin@adventurepatch.org.au W: adventurepatch.org.au
Should be Empty: