BMPA Membership Form

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

DayMonthYear
Date

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

Other
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

DayMonthYear
Date

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

Bacchus Marsh Platypus Alliance - Membership Form