BMPA Membership Form

Adult #1

(Please complete details for first adult applicant below...)
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

Suburb / TownState / Territory

Post Code
Phone Number (include area code if relevant)
Why are you interested in joining Bacchus Marsh Platypus Alliance?
Do you have any special skills, interests, etc. you would like to bring to Bacchus Marsh Platypus Alliance? (You won't be assessed on these - it's just in case there is anything you'd like to share or be involved in).
Are there any skills or knowledge you would like to gain or develop further by being part of Bacchus Marsh Platypus Alliance?
Is there any other information you'd like to add?
Please read the following statements, and sign by typing your name below if you agree:
- I wish to become a member of Bacchus Marsh Platypus Alliance Inc.
- I support the purposes of Bacchus Marsh Platypus Alliance Inc.
- I agree to comply with the rules of Bacchus Marsh Platypus Alliance Inc. and the rules of Landcare Victoria Incorporated, of which Bacchus Marsh Platypus Alliance is a member. These include respecting the rights and dignity of others, refraining from any discrimination based on race, ethnicity or gender, and following the child safe policy which Bacchus Marsh Platypus Alliance has adopted.
Sign by typing your full name below:*

First NameLast Name
Date*

MonthDayYear
Date

Which category would this young person like to apply for? (You can select more than one option)*

Platypus Pals (kids club receiving platypus news, stickers, and invited to attend kid's activties)Associate membership of Bacchus Marsh Platypus Alliance Inc. (be invited to attend Bacchus Marsh Platypus Alliance members' meetings, events and activities. The same as full membership, but without full adult voting rights).Volunteer (be invited to events, activities and volunteer opportunities suitable for age group)
Child's / Teen's Name*

First NameLast Name
Parent / Guardian Name #1*

First NameLast Name
Parent / Guardian Name #2

First NameLast Name
Contact Email Address*
example@example.com
Contact Phone Number #1 (include area code if relevant)
Contact Phone Number #2 (include area code if relevant)
Town or suburb*
Child's / Teen's month and year of birth
MM/YYYY
Why is the applicant interested in joining Bacchus Marsh Platypus Alliance?
Does the applicant have any special skills, interests, etc. they would like to bring to Bacchus Marsh Platypus Alliance? (You won't be assessed on these - it's just in case there is anything you'd like to share or be involved in).
Are there any skills or knowledge the applicant would like to gain or develop further by being part of Bacchus Marsh Platypus Alliance?
Is there any other information you'd like to add?
Would you like to receive a sign-up pack (stickers and magnet) from Bacchus Marsh Platypus Alliance?

Yes pleaseNo thanks
Postal Address

Street Address

Street Address Line 2

Suburb / TownState / Territory

Post Code
For completion by young person applying for Associate Membership...
Please read the following statements, and sign by typing your name below if you agree:
- I wish to become an associate member of Bacchus Marsh Platypus Alliance Inc.
- I support the purposes of Bacchus Marsh Platypus Alliance Inc.
- I agree to comply with the rules of Bacchus Marsh Platypus Alliance Inc.
Sign by typing your full name below:*

First NameLast Name
Date*

MonthDayYear
Date

Name of organisation or association*
What is the type of organisation or association?*

Incorporated associationUnincorporated associationCompanyBusinessTrustOther
Your name (as representative of the organisation or association)*

First NameLast Name
Your position in the organisation or association*
Contact email address*
example@example.com
Phone Number (include area code if relevant)
Address of the organisation or association*

Street Address

Street Address Line 2

Suburb / TownState / Territory

Post Code
What does your organisation or association do?
Why is your organisation or association interested in joining Bacchus Marsh Platypus Alliance?*
Does your organisation or association have any special skills, interests, etc. you would like to bring to Bacchus Marsh Platypus Alliance? (You won't be assessed on these - it's just in case there is anything you'd like to share or be involved in).
Are there any skills or knowledge your organisation or association would like to gain or develop further by being part of Bacchus Marsh Platypus Alliance?
Is there any other information you'd like to add?
Please read the following statements, and sign by typing your name below if you agree...

The entity named below:
- wishes to become a member of Bacchus Marsh Platypus Alliance Inc.
- supports the purposes of Bacchus Marsh Platypus Alliance Inc.
- agrees to comply with the rules of Bacchus Marsh Platypus Alliance Inc. and the rules of Landcare Victoria Incorporated, of which Bacchus Marsh Platypus Alliance is a member. These include respecting the rights and dignity of others, refraining from any discrimination based on race, ethnicity or gender, and following the child safe policy which Bacchus Marsh Platypus Alliance has adopted.
Name of entity (organisation or association):*
Sign by typing your full name below:*

First NameLast Name
Date*

MonthDayYear
Date

Please press "submit" below to submit this form.
Should be Empty:

Bacchus Marsh Platypus Alliance - Membership Form