Leukodystrophy Australia Recurring Credit Card Donation Form

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Membership - (for people who are directly affected by Leukodystrophy)Free

Membership - Annual Subscription$25.00 AUD

Members’ Quarterly Newsletter - (Emailed)Free

Members’ seasonal Newsletter via Australia Post$25.00 AUD

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Thank you for your planned membership by Direct Deposit or Cheque. This process requires you to either post a cheque, or complete your donation via your own online banking.

Direct Deposit details:

Bank of Melbourne
Australian Leukodystrophy Support Group Inc
BSB: 193 879
A/C: 457864204
Please enter your name in the Reference field.

Cheque:

Payee: Australian Leukodystrophy Support Group Inc

Mailed to:

Leukodystrophy Australia
P O Box 2550,
Mount Waverley
VICTORIA 3149
AUSTRALIA

Membership Type

Important: Please read the information below about membership eligibility, benefits and responsibilities, and legal requirements relating to the Leukodystrophy membership register.

Peer Support

I would like contact to find out more about possible future Committee or volunteering in some way.

Briefly outline any skills and experience relevant to this role:

Please let us know the type of Leukodystrophy affecting your family or any other information you would like to share:

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To cancel a recurring membership, please contact us by email or phone and we will handle this offline.

PE TEST FORM ONLY

Membership Type (online payment)