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Membership application

A valid email address. All emails from the system will be sent to this address. The email address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by email.
Provide a password for the new account in both fields.
Personal Information
Date of Birth
Gender
Contact Details
Postal Address
Health Information
Do you have diabetes?
Type of diabetes
Do you use insulin?
Do you have a cardiac condition
Concession Card Details
Select the newsletter(s) to which you wish to subscribe.
Membership Options
Membership type
Only applicable if you are registering as an Extra Family as above.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.