Beyond Disability Inc Membership Form

Please note: BDI helps housebound physically and mobility disabled individuals, Veterans (widows or carers).  In the event your application is refused, your initial payments will be refunded.  
Need help to keep up with technology in this fast changing world of computers, tablets and phones? Our volunteers are here to help you with all forms of technology. We help school age children, adults, carers and veterans. 
For a very minimal cost our volunteers will give you all the advice you need to meet your technical problems, whether you have your own laptop, tablet or desktop computer, or would like our equipment.
Email *
Application Details:  I desire to become a member of BDI and wish to apply to receive the Beyond Disability (BDI) service and provide the following support of my application.

Full name of Applicant:
 *
Address: (including Suburb and Postcode) *
Contact Number: *
Description of Disability: *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Veterans - Service Number (N/A if don't have one)
Second Contact Name *
Second Contact Address:  (including Suburb and Postcode) *
Second Contact's Number *
In making this application for membership I confirm that: (Check box which is applicable to you) *
Required
2. I have read and understood the "BDI Services Terms and Conditions"? T's & C's  *
Required
3. I have read and understood the "BDI Privacy Policy "and I agree to BDI collecting my personal information for the purpose of processing my membership application and otherwise using it in accordance with the BDI Privacy Policy. I understand that I can seek access to the personal information that BDI holds about me and that if I do not provide all information sought by BDI in this application form, BDI may not be able to  process my application or provide me with all the service I am seeking.  *
Required
PRIVACY DISCLOSURE AND PHOTOGRAPH CONSENT
4. I agree to BDI using my personal information (which may include my first name, age and disability) for the purpose of :
a) BDI contacting support groups on my behalf, to promote the BDI program(s) and/or obtain assistance or sponsorship support for me or for other BDI members, and in doing so may disclose personal information about me and my circumstances to these parties
 *
Required
b) BDI publishing photographs of me in it's publications, on any multimedia sites in order to promote BDI program(s). *
Required
5.  Please indicate below  personal details to be disclosed without prior written consent and describe any other you would like us to adhere to relating to the disclosure of your personal details. *
FORMATION OF AGREEMENT
6. You acknowledge and agree that once you have been notified that your membership application has been accepted and approved by BDI.  This document and the BDI Service Terms and Conditions, referred to in item 2 above, will form your membership Agreement with BDI, you will be bound by the terms and conditions contained within your Membership Agreement 
 *
Required
7. If the applicant is a child, this application must be signed by a parent or nominated carer of the child. *
Required
SIGNATURE (printing your name is the same as signing it)
Signature of applicant/parent/carer *
Date *
MM
/
DD
/
YYYY
I, a member of BDI, nominate the applicant(s), for membership of BDI
Name
Date *
MM
/
DD
/
YYYY
PAYMENT OPTIONS
All applications for membership will need to include an initial payment which is: 
8. The first Quarter's programme fee of $33 (inc GST).  If you have your own broadband connection.  Then we prefer $11 monthly payment, or $33 quarterly payment as bank debit below 
9. Or the first Month's payment of $23 (inc GST) if you require BDI Wireless Broadband.  Thereafter we prefer $23 monthly payment or $69 quarterly payment by bank debit ad below.

Note: If your application is unsuccessful the initial payment will be refunded.

PAYMENT OPTIONS 
Direct credit to our bank account.  
Account Name: Beyond Disability Inc
Account Number: 131827487  BSB: 633-000
Bank: Bendigo Bank, Pearcedale
Reference: (Your surname and initials here) ie. Beyond. D
Ask your bank if they can setup telephone banking to help you pay your program fees on  a timely basis.

If you need to discuss financial distress then please get in touch  with us, and if you qualify we will send sponsorship paperwork to you.  Contract our secretary@bdi.org.au
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms