New Membership Application

Please enable JavaScript in your browser to complete this form.

Title *

First Name *

Surname *

Date Of Birth *

Phone (Mobile or Landline) *

Email *

Occupation

Gender *

Members Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name of Parent, Guardian (If under 18), or Carer

Relationship to Member *

Are you NDIS participant? *

Participant NDIS Number *

NDIS Plan Type *

Type Of Membership (Please select 1 only)

Checkboxes *

Ordinary Member (Paraplegia)
Ordinary Member (Quadriplegia)
Supporting Member (Carer)
Board Member

Supporting Members cannot obtain free PBS items as part of membership

Ordinary or Board Member – Person with a spinal cord injury or related disability, or an appointed Board Member.

Has voting rights and access to all services and membership benefits.

Supporting Member – Person who is a carer or with an interest in spinal cord injury.

Has no voting rights and cannot stand for the Board of Forward.

As an Ordinary member, will you require access to obtain PBS items ? *

If Yes, we will be required to obtain your medicare details, so we can claim benefits on your behalf.

Medicare Details (Member)

Please provide details as shown on Australian Medicare Card.

First Name *

Surname *

Individual Reference Number *

Medicare Card Number *

Medicare Expiry Month *

Medicare Expiry Year *

Injury Details

Date of Injury *

Cause of Injury *

Level of lesion *

Any associated disabilities (Multiple Selection)

Cerebral Palsy
Multiple Scierosis
Muscular Dystrophy / Atrophy
Spina Bifida
Alzheimer’s disease
Amputee
Arthritis
Brain injury
Cancer
Diabetes
Hemiplegia
Incontinence
Intellectual/developmental
Parkinson’s disease
Partial paralysis
Polio
Stroke/CVA (cerebral vascular accident)
Other

If you do not have a disability, are you

Family/spouse of a person with a disability
An advocate for a person with a disability
Employed in a non-government disability service/organisation
Employed in a State, Federal or Local Government department or service
Other

National Privacy Principles *

Confirmation – Forward complies with the National Privacy Principles (NPP). If you would like to view Forward’s privacy statement, please refer to the website at www.fas.org.au, or contact us and ask to speak to our privacy officer. The information you have provided on this form will be used to provide you with membership services outlined on the form and your answers regarding your disability will be used for statistical purposes only. All other information herein will be kept confidential. Updated 10 December 2021. In addition, i confirm that i meet the membership criteria for the nominated membership above and agree to abide by the rules of the Association (a copy of the constitution is available on request)

Name of Member, Guardian or carer (Electronic Signature) *

Is your primary language English *

What is your primary language *

Do you require the use of an interpreter? *

Are you Aboriginal or Torres Strait Islander origin? *

What is your primary purpose for becoming a member of Forward? *

To be part of a spinal cord injury network
Access Pharmaceutical Benefits Scheme bowel preparation products
To support the work of Forward
Appointment to Board of Directors

(Please select 1 only)

How would you like to receive our Forward Newsletter ? *

Printed copy
Electronic copy
Do not require

(Please select 1 only)

How did you hear about Forward ? *

Forward Staff Support Coordinator
C.A.A.S / C.A.P.S
Clinical Nurse Consultant
Community Nursing / Health
General Practitioner
Hospital / Spinal Unit
Residential Aged Care
Aged Care assessment team
Other

(Please select 1 only)

Are you a member of other disability related organisations?

List other disability related organisations *

New Products or Services

Forward and its related trading names introduce new products/ services/news from time to time. Tick the box if you do NOT want to be notified of these developments through our direct marketing mailings.

Internal Use

Ordinary Membership Payment ($20.00 incl GST) – Select 1 Only *

Free (Injury is within 12 month period)
Is Required

Confirm that I meet the membership criteria for the nominated membership above and agree to abide by the rules of the Association. (A copy of the constitution is available on request)

Supporting Membership Payment ($15.00 incl GST) *

Is Required

Confirm that I meet the membership criteria for the nominated membership above and agree to abide by the rules of the Association. (A copy of the constitution is available on request)

Ordinary Membership Donation (Amounts over $2 are tax deductible) *

Would like to make a donation
No donation at this time

Supporting Membership Donation (Amounts over $2 are tax deductible) *

Would like to make a donation
No donation at this time

Ordinary Membership Donation Amount *

Supporting Membership Donation Amount *

PAYMENT

Reference NDIS of

Checkboxes 1 *

Confirming Payment is not required at this time (Ordinary Member, injury within 12 months, and no donation.

Checkboxes 2 *

Confirming Payment has been taken for membership and or donation.

Name of team member who has taken payment, or (Confirming payment not required) *

Payment Receipt Number *

Notes (For communication to IT)

New Membership Application

Type Of Membership (Please select 1 only)

Medicare Details (Member)

Injury Details

Internal Use

PAYMENT

Stay up-to-date