New Membership Registration Form

Name*

First NameLast Name

Email*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Next of Kin *

First NameLast Name

Next of Kin Contact Number *

Please enter a valid phone number.

DOB ~ Our members are so important to us, we would love to be able to reach out to you when it’s your special day and send you warm happy birthday wishes. *

MonthDayYear

Which statement best describes you?*

I have MSMy family member has MSI want to be involved and support people living with MS

How do you wish to receive Central Coast Branch newsletters? To keep costs down, we do prefer to send via email option, however if this is not optional for you than we are more than happy to mail out*

EmailMail

There is a membership fee of $5 per person payable upon registration and will be due for renewal every 1st of June. This is to make it easier for us to track and keep on top of. You can pay this via direct debit to;

NAME: Central Coast Branch of the Multiple Sclerosis Society of NSW

BSB: 062-544
ACCT: 1005-4255

Reference: Your name

I understand, and agree to pay $5 membership fee annually*

YesNo

You can pay your renewal fees in person every year at the annual general meeting or via direct deposit with the banking details above.

Thank you for reaching out. We welcome you to participate as much or as little as you like. We’re all in this together. For any assistance, questions or just to talk, please don’t hesitate to contact us on;

ccmsb.president@gmail.com or ccmsb.secretary@gmail.com

All General & AGM Meeting dates will be advised on our Facebook page

https://www.facebook.com/MsCentralCoastBranch

Please verify that you are human*

This form is for the Central Coast MS Branch only, so we can update member records. Member records may only be accessed by elected executive members of the branch. MS Limited may ask to view member records at any time as per our contract agreement with them.

New Member Registration Form