Print Membership Form

Print the Membership Form or fill in online.
Membership fee to be paid upon submission of details through website (PayPal).
You may pay with your credit card or PayPal account.


Your Personal Details

First Name(s)
Surname
Title ProfDrMrMrsMsOther
Postal Address
Suburb
State
Postcode
Email Address
Home Phone
Business Phone
Mobile

Your Membership Choices

Category Family MemberHealth ProfessionalSupporterOther

I hereby apply for Association membership with an annual fee of $15.I wish to renew my Association membership with an annual fee of $15.

Payment

(GST - not Reportable)

Please send me an invoice to my Email AddressPostal Address

Additional Identification Choices for Family Members

This section is optional. Providing this information helps us to ensure that you are notified of news and events that meet your particular needs. You may tick more than one box.
I have been diagnosed as having Huntington's Disease.I have tested positive but have not been diagnosed with the disease.I have tested negative.I have a parent with Huntington's Disease but do not know if I have the Huntington's gene.I have a grandparent and/or aunts and uncles with Huntington's Disease but don't know if my parent has the Huntington's gene.I am caring for a person with Huntington's Disease, have cared for someone in the past or expect to be caring for someone in the next few years.I have a close family member who has Huntington's Disease but I am not the main carer.

Newsletter and Other Communications

All members will receive an emailed copy of the newsletter unless one of the following boxes is ticked.
I do NOT wish to receive the newsletter.Please MAIL me a printed copy of the newsletter and other communications.Our household has MULTIPLE MEMBERSHIPS. Please send only one copy of the newsletter and other communications to our household.