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 13837 1265
  • 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
Please select your title.
Please let us know your title.
Please let us know your first name.
Please let us know your last name.
Please select your membership type
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PHONE AND EMAIL
Please tell us your landline or mobile number.
Please let us know your email address.
ADDRESS
Please tell us the number and street name of your address.
What is your suburb?
Please give us your Post Code
What state do you live in?
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