Membership Type (Please Circle)

1 Year Membership

5 Year Membership

5 % Discount

10Year Membership

10 % Discount

New Member - First Year 10 % Discount

SHORT STATURED PERSON:

 A short statured person 18 years and over

$37.00

$175.75

$333.00

$33.30

PARENT/GUARDIAN MEMBER:

 One parent or guardian of a short statured person under 18 years of age, and short statured dependant students  (membership includes the short statured person(s))

$37.00

$175.75

$333.00

$33.30

FAMILY MEMBERSHIP:

Both parents or guardians of a short statured person under 18 years of age, and short statured dependant students (including the short statured person(s), and dependant sibling(s))

$68.00

$323.00

$612.00

$61.20

ASSOCIATE MEMBER:

Any interested natural person who does not come under any of the previous categories above.

$37.00

$175.75

$333.00

$33.30

CORPORATE MEMBER:

$37.00

$175.75

$333.00

$33.30

LIFE MEMBER:

$0.00

$0.00

$0.00

$0.00

TITLE (circle)

MR

MRS

MISS

MS

DR

PROF

OTHER

FAMILY NAME:_________________________

GIVEN NAMES: ________________________

FULL ADDRESS: ____________________________________

POSTCODE:_________

POSTAL ADDRESS (IF DIFFERENT FROM ABOVE):__________________________________

PHONE NUMBER

(H): ___________________      

(w):_________________

(M):___________________

EMAIL:_______________________________________________________________________

(I do / do not agree for my email address to be placed on the public Email directory of the SSPA)

RELATIONSHIP TO SHORT STATURED PERSON:___________________________________

LANGUAGES SPOKEN OTHER THAN ENGLISH:____________________________________

PAYMENT DETAILS

Total Membership Subs

Amount:                                                                        $________________________

Donation to Careers & Vocational Guidance Fund: $________________________

(Donations $2.00 and over are tax deductible)

Total:                                                                             $________________________

FORM OF PAYMENT

(Please circle)

CASH   c    CHEQUE  c

(Please make cheques

 payable to SSPA)

VISA c  BANKCARD c  MASTER CARD c 

(Please complete details below)

Card Number:_______________________________

Name (as appears on card):

 

____________________________  

Expiry Date: _______________________ 

Signature:_________________________

         
Please return to:

Treasurer, SSPA

3 Danielle Cres. Heathmont,  Vic 3135

If you would like to discuss any aspect of your membership, contact Malcolm Paton on
(03)9729 4912

DETAILS OF SHORT STATURED PERSON

FAMILY NAME:___________________

GIVEN NAMES:________________________

DATE OF BIRTH:_________________

OCCUPATION:_________________________

DRIVE A VEHICLE: YES / NO

MEDICAL DIAGNOSIS (IF KNOWN):

Are you willing to have your name given to parents of a child with the same condition:
Yes / No

Signed: ____________________________

Date:___________________

DETAILS OF SHORT STATURED PERSON

FAMILY NAME:___________________

GIVEN NAMES:________________________

DATE OF BIRTH:_________________

OCCUPATION:_________________________

DRIVE A VEHICLE: YES / NO

MEDICAL DIAGNOSIS (IF KNOWN):

Are you willing to have your name given to parents of a child with the same condition:
Yes / No

Signed: ____________________________

Date:___________________

DETAILS OF SHORT STATURED PERSON

FAMILY NAME:___________________

GIVEN NAMES:________________________

DATE OF BIRTH:_________________

OCCUPATION:_________________________

DRIVE A VEHICLE: YES / NO

MEDICAL DIAGNOSIS (IF KNOWN):

Are you willing to have your name given to parents of a child with the same condition:
Yes / No

Signed: ____________________________

Date:___________________