LVSM Membership Form

Personal Information

Used to identify you for membership purposes
Given Name/s*
Last Name*
Preferred Name
Birth Date*

DayMonthYear
Date
Gender
Contact Details

Used to contact you for membership purposes and to notify you of upcoming events
Home Phone
Include area code
Mobile Phone
Email Address*
example@example.com
Newsletter

Yes, subscribe me to this newsletter.
Address*

Address

Street Address Line 2

SuburbState

Postcode
Address

Used to send you mail pertaining to membership and helps when determining event location
Street Address
Suburb*
State*
Postcode
Country
Insurance / Australian Living History Federation (ALHF)

The ALHF is LVSM’s body for personal and public liability insurance. Information provided above may be shared with them to ensure you are covered.
Are you already registered with ALHF with another group?*

YesNo
LVSM will register you with the ALHF and LVSM will become your primary group.
Annual fee: $45, $5 Admin plus $40 to cover ALHF
LVSM will become a secondary group of yours with the ALHF. Your primary group will control your insurance payments.
Annual fee: Only $5 for Admin.
What is your ALHF Number?*
Please list any other ALHF groups you are in*
Please list any other ALHF groups you are in: In order, e.g. Primary Group, Secondary Group, Tertiary Group, etc.
Signature

By signing below, I agree with the purposes of the Late Victorian Society of Melbourne Inc. (LVSM), agree to abide by its rules, and consent to my information getting shared with the Australian Living History Federation.
Signed*

Clear
Date

DayMonthYear
Date
Should be Empty:

Membership Form

Interest Survey

Personal Information

Contact Details

Address

Insurance / Australian Living History Federation (ALHF)

Signature