Membership Form

Name

Email Address

Street Address

Suburb

State

Postcode

Phone

Member details Member details I have cystic fibrosis My child has cystic fibrosis I do not have cystic fibrosis/friend or family

Gender Gender Male Female Other

Date of Birth (dd/mm/yyyy)

Child's name

Child's date of birth (dd/mm/yyyy)

Child's Gender Child's Gender Male Female Other

Membership category Membership category Concession Membership - $15.00 (please provide Concession card number below) Standard Membership - $30.00 (CF adults without a concession card) Friend of Cystic Fibrosis Queensland - $50.00 (family member, friend or wish to support) Corporate Membership - $200.00

Concession Card Number

Any additional information

Payment method Payment methodVisaMastercardDirect transfer

Direct transfer Direct transfer Direct transfer: BSB: 633 000 Account number: 184 090 926, please put your first and last name in the reference field and email a transaction reciept to claims@cfqld.org.au

Name on card

Card Number

Card expiry (mm/yy)

I am interested in finding out more about/being involved in: I am interested in finding out more about/being involved in: Events and fundraising Volunteering Community Advisory Committee

I would like to know more information about: I would like to know more information about: Trusted Care

Declaration Declaration I declare that the above information is true and correct