Friends of Black Rock House Membership Form

Membership fees are $20 for families and $15 for individuals per annum.

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

via EFT deposit to BSB 633000 A/c 165508284
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 *

Membership Type *

Single

Family

First & Last Name (plus age if a child)

Phone *

Your Email *

Street & Number *

Suburb *

Post Code *

State *

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