Australian Huntington's Disease Association (Qld)
Application for Membership
Any adult interested in furthering the objectives of the Association is eligible for membership.

Title............... Name..........................................................................

Address.............................................................................................
......................................................................Postcode......................

Telephone ............................................Fax .....................................

Annual Fee for single membership is $13.20, or a special family subscription of $19.80 per year is available if more than one adult family member, living at the same address, wishes to join. Please nominate names of other adult members to be included.

(1)....................................................
(2)....................................................
(3)....................................................
(4)....................................................

Could you please tick the appropriate box(es) below:

[ ] I hereby apply for single membership, and my annual fee of $13.20 is enclosed. (Price includes GST).

[ ] I hereby apply for family membership and my annual fee of $19.80 is enclosed. (Price includes GST)

[ ] I am unable to pay the membership fee at present, but wish to receive newsletters.

[ ] Please delete my name from the membership list.

[ ] I am a professional working with HD families and would like to receive newsletters.

Profession...............................................Workplace.....................................

   Membership enclosed $
        Donation enclosed $____
Total amount enclosed $

Signed.......................................

Date..........................................

Donations to AHDA (Qld) Inc of $2 or more are deductable for tax purposes.
Please print, complete and return this form to:

The Membership Secretary,
AHDA (Qld) Inc
 P O Box 635
Annerley Qld 4103