Fillable MEMBERSHIP APPLICATION FORM ACOUSTIC NEUROMA ASSOCIATION AUSTRALIA Inc (National Asthma Council Australia)

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MEMBERSHIP APPLICATION FORM ACOUSTIC NEUROMA ASSOCIATION AUSTRALIA Inc (National Asthma Council Australia)

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Incorporation Act No. A0011390R
ACOUSTIC NEUROMA ASSOCIATION AUSTRALIA Inc
MEMBERSHIP APPLICATION FORM
Name Email address (print clearly)
Street address City/Town
Post code State Phone Number/Mobile
Date of Birth Gender
Current Occupation:
Membership may include an additional family member for the one annual fee
Additional Family Member Name Relationship
Occupation
I agree to support the purposes and constitutional rules of the Acoustic Neuroma Association
Australia
Signed: Date:
How did you hear about the ANAA?
Have you spoken to a State Contact Officer ? If so Who?
Are you agreeable to have your contact details circulated on the membership list?
Would you like to make contact with other members?
ANNUAL MEMBERSHIP FEES: $40.00 (Cheques or money order payable to ANAA)
Please return this form and fee to:
James De Graaff
P.O. Box 462
Colac Vic 3250
membership@anaa.org.au
Or if using Direct Debit complete details below:
Account Name: ANAA Inc.
Bendigo Bank
BSB: 633 000 Account No: 160656377
Please state your name in reference when direct debiting. All donations
will be acknowledged by Receipt and are tax Deductible.
The following information is collected to inform the association on member needs, to support future
planning and those newly diagnosed.
MEDICAL INFORMATION
DIAGNOSIS DETAILS:
Date first diagnosed?
Who diagnosed you and what
was their medical expertise?
Which side is your Acoustic
Neuroma? Left or Right
Date of last MRI
Size of Tumor Have you undergone any treatment?
Please provide details:
Where were you treated? Treating
Doctor
If not, are you considering any
particular treatment?
Do you currently experience any of the following?
Facial nerve damage
tinnitus
Headaches
Memory Issues
Memory Loss
Hearing Loss
Altered Taste
Other, if so what?
Have you undertaken any
treatment for any of the above?
Do you provide consent for your diagnosis details to be included on our data base accessible to
members only?
Any other comments:
Office Use only:
Contact Person:____________________________Registered on member list ______________Info pack sent _______ Receipt No ____________
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MEMBERSHIP APPLICATION FORM ACOUSTIC NEUROMA ASSOCIATION AUSTRALIA Inc (National Asthma Council Australia)

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Completed 19 November 2020

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