Online Membership Application Form

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Breast Cancer Action Group NSW
Electronic Membership Application Form

1. Individual Membership

		Breast cancer survivor		Breast cancer patient
		Family member		Carer
		Health professional

Other (please specify)
Year(s) experienced

2. 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+

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

Administrative			Communications and media		Representational
Fundraising			Policy development		Newsletter/website

Other (please specify)

4. 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 click in box)

5. 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: $

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

	Press this button once after completing the form. This will send the information you have typed in the boxes above to us by email.
	Click this button to clear all information from the form (use this only if you want to start again)

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