Friends of Black Rock House Membership Form

Membership costs $20.00 for families and $15.00 for individuals per year with all money going towards the support of our community activities.

Please complete the form below. Once you have done this you may pay you membership fee as follows:

• via online deposit to BSB 633-000 A/c 165 508 284
• by mailing your cheque made out to Friend of Black Rock House Inc to PO Box 200, Black Rock VIC 3193

Thank you - we look forward to welcoming you aboard.

Membership Form

NAME AND FAMILY DETAILS

Title(*)

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Your Title(*)

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First Name(*)

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Last Name(*)

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Membership Type(*)

SingleFamily

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First & Last Name (plus age if a child)

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First & Last Name (plus age if a child)

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First & Last Name (plus age if a child)

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First & Last Name (plus age if a child)

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PHONE AND EMAIL

Phone(*)

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Your Email(*)

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ADDRESS

Street & Number(*)

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Suburb(*)

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Post Code(*)

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State(*)

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Anti-Spam Verification(*)

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