Membership Application Form

Breast Cancer Action Group NSW
Membership Application Form
Home > Contact > Membership Application Form

Mail to:	Breast Cancer Action Group NSW PO Box 5016 Greenwich NSW 2065
Fax:	02 9436 1755

1. Individual Membership

Breast cancer survivor		Breast cancer patient
Family member		Carer
Health professional

Other (please specify)

Year(s) experienced

Personal Details

Title

First Name

Surname

Postal Address

Suburb

City

State

Postcode

Occupation

Phone (day)

(evening)

(mobile)

Fax

Age group
18-29		30-49
50-69		70+

2. What skills could you contribute to the Breast Cancer Action Group?

Administrative			Communications and media		Representational
Fundraising			Policy development		Newsletter/website

Other (please specify)

3. Consumer training

A Cancer Consumer Advocacy Training course is being planned to offer skills and confidence for cancer consumers interested in being consumer representatives or advocates; 3-4 days over 2 weekends.

Please send me details

(Please tick)

4. Donations

BCAG NSW is entirely dependent on donations to operate. There is no fee to join. Any donation will help the VOICE to be heard. Please mail cheques or postal orders (made payable to Breast Cancer Action Group NSW) with this application form and if a tax deductible receipt is required, please also enclose a stamped, self-addressed envelope.
Contribution Amount: $

5. What issues would you like to flag as a BCAG NSW member?

6. Completed forms

Please post/fax completed forms to:
Breast Cancer Action Group NSW
PO Box 5016
Greenwich NSW 2065
Fax: 02 9436 1755

For further enquiries contact Breast Cancer Action Group NSW by emailing us.

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