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

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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