MEMBERSHIP / RENEWAL NOTICE

I/We wish to join/renew our membership of The Queensland Association for People with Spina or Hydrocephalus Inc. for the current year to the 30th June 1999.

Subscription: $	Donation: $	Total: $
(Donations to the Association are tax deductible)
Name
Address
Post Code
Your email address
Contact Number
Date
The subscription is TEN DOLLARS per member

PLEASE SELECT:
		I am a parent of a child with Spina Bifida or Hydrocephalus.
		I am a client with Spina Bifida or Hydrocephalus.
		I am the carer of a person with Spina Bifida or Hydrocephalus.
		I am interested in the Association.

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