Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Title *Please SelectMrMrsMsDrOtherFirst Name *Surname *Date Of Birth *Phone (Mobile or Landline) *Email *Members Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryName of Contact Person (Optional)Relationship to MemberPlease SelectAuntBrotherBrother in LawCarerCase ManagerCousin/relativeCommunity Services OfficerDadFather in LawDaughterDaughter in LawFriendGrandadGrandaughterGrandmotherGrandsonGuardianHusbandMumMother in LawNephewNieceNext of KinParentPartnerSelfSisterSister in LawSocial WorkerSonSon in LawTrusteeUncleWifeYouth Development OfficerUnknownAs a member, will you require access to obtain PBS items ? *YesNoIf 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 *Please Select123456789Medicare Card Number *Medicare Expiry Month *Please Select010203040506070809101112Medicare Expiry Year *Please Select20242025202620272028202920302031203220332034203520362037203820392040 Type Of Membership Checkboxes *Ordinary Member (Paraplegia)Ordinary Member (Quadriplegia)Supporting Member (Carer)Board MemberOrdinary 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. Injury Details Date of Injury *Cause of Injury *Please SelectDisease RelatedFall RelatedRoad & Transport InjurySport InjuryOtherOther associated disabilities (Multiple Selection)Acquired Brain InjuryAmputeeCerebral PalsyMultiple ScierosisMuscular Dystrophy / AtrophyParkinsons DiseaseSpina BifidaStrokeOtherAre you Aboriginal or Torres Strait Islander origin?YesNoDo you require the use of an interpreter?YesNoHow did you hear about Forward ?Forward Staff Support CoordinatorC.A.A.S / C.A.P.SClinical Nurse ConsultantCommunity Nursing / HealthGeneral PractitionerHospital / Spinal UnitResidential Aged CareAged Care assessment teamOtherMembership Other Expiry Name Annual membership period is from 30th September – until 29th September the following year. People with spinal cord injury receive free membership for the first 12 months from date of injury.Confirmation *Ordinary Membership ($20.00 including GST). 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)Confirmation – Supporting Member *Supporting Membership ($15.00 including GST). 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)Confirmation – Ord Member – Free Membership until 30th Sept Current Year *Supporting Membership ($15.00 including GST). 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)Confirmation – Ord Member – Free Membership until 30th Sept THE NEXT YEAR *Supporting Membership ($15.00 including GST). 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)I would like to pay my membership by: *Credit Card or PaypalBPAYDirect DepositChequeMoney OrderPayPal Commerce (Please select Paypal or Credit Card) *PayPal CheckoutCredit CardCard NumberExpiration DateSecurity CodeCard Holder NameDirect DepositForward Ability Support: BSB xxxxx Account Number: zzzzzzzzzzzzzzzzzzzCheque Money OrderPlease make payment to: Forward Ability Support. Post cheque money order to cxxxx fblah blah. Once payment has been recieved your membership request will be reviewed.. Please select SUBMIT below.Submit