Friends of Black Rock House Membership Form

Membership fees are $25 per household per year and $500 for lifetime membership.

Please complete the form below. Once completed please pay your membership fee as follows:

via EFT deposit to BSB 633000 A/c 138 371 265
by mailing your cheque made out to Friends of Black Rock House Inc to PO Box 200, Black Rock VIC 3193

Thank you - we look forward to welcoming you

NAME AND FAMILY DETAILS

Your Title *

For example Mr, Ms, Mrs, Miss, Dr

First Name *

Last Name *

Your birthdate *

DD/MM/YYY

Membership Type *

Household $25

Lifetime $500

Phone *

Your Email *

Street & Number *

Suburb *

Post Code *

State *

reCAPTCHA Invisible *

Phone