Registration Form for PADA (AUSTRALIA)

Login Credentials

Create login credentials to access your membership information later

Username:

Choose a username for logging into your account

Password:

Choose a secure password

Confirm Password:

Please tick which state branch

PADWA

PADNSW

PADVIC

PADQLD

PADTAS

PADSA

PANT

Title:

Mrs

Miss

Other

Surname:

First Name:

Date of Birth (DOB):

Residential Address:

Suburb:

State:

Postcode:

Phone:

Email:

Dance Sport license number:

Demographic Information

Gender:

Male

Female

Other

Speaks a Language Other than English at Home:

Yes

Do You Identify as an Indigenous Australian?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, Aboriginal and Torres Strait Islander

Legal Guardian Information (if applicable)

Legal Guardian's/Parent/Carer Full Name:

Relationship to Applicant:

Phone:

Email:

Preferred Email Communication:

Member

Legal Guardian

Both

Emergency Contact is Same as Legal Guardian

Emergency Contact

Name:

Phone:

NDIS and Support Services

NDIS Number:

Yes No

Are You on Disability Support Pension Card?

Yes No

Aged Care Home Care Package?

Yes No

ACROD Parking Permit?

Yes No

Access to the Community

Do You Have Support People at Events?

Yes No

Are You a Companion Card Holder?

Yes No

Using a Wheelchair or Similar Device?

Yes No

Do You Need Help with Hair and Makeup Before Events?

Yes No

Diagnosis Information

Please Describe Your Diagnosis:

Attach copies of any current report, or recent letters from your doctor.

Primary Diagnosis:

Secondary Diagnosis:

Supporting Documents:

Competition Category

All Abilities

Blind

Deaf

Para

Visual

Other:

PADWA Merchandise

Please indicate if you have:

PADWA Polo Shirt $

PADWA Jumper $

PADWA Backpack $

Application Statement (We need to work more on this)

I confirm that the information in this application is correct.

I am a resident of Australia.

I understand the terms and conditions of PADA (still being sorted).

I understand I will need to help in at least 1 fundraising event (e.g., sausage sizzle, quiz night).

Subscription renewal due before 1st February of each year.

Name and Signature of Member:

Date:

Name and Signature of Legal Guardian (if applicable):

Date:

Donation Information

Would You Like to Donate?

$100

$50

$25

$10

No donation at this time

(Note: Donations of $2.00 and over are tax-deductible and GST exempt.)

RENEWING YOUR MEMBERSHIP

Would you like us to automatically renew your membership each year?

Yes please, renew automatically

No thanks, please send me a membership form when it falls due in 12 months

How did you hear about PADA?

Disability services

Service provider

Support group

Therapist

School

Other

Payment Information

Membership Fee: $10.00

Donation: $0.00

Total: $10.00

Credit or debit card

What You Get for PADA Membership

Login Credentials

Please tick which state branch

Demographic Information

Legal Guardian Information (if applicable)

Emergency Contact

NDIS and Support Services

Access to the Community

Diagnosis Information

Competition Category

PADWA Merchandise

Application Statement (We need to work more on this)

Donation Information

RENEWING YOUR MEMBERSHIP

How did you hear about PADA?

Payment Information