Bequest - Muscular Dystrophy WA

Friends With Benefits Membership Form
Contact Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbState

Postal Code
Email Address*
example@example.com
Phone Number*
Let us know why you are signing up to be a Friend With Benefits (eg. you know someone with an NMC)*
Payment Details

You will need to set up a recurring payment to us through your financial institution. We will send you our bank details once this form has been submitted. Please indicate below your payment frequency and start date so we can put you on our membership list and keep an eye out for your first payment.
Direct Transfer Payment Frequency

Select whether you wish to make your recurring payments weekly, fortnightly, monthly or yearly upfront. Please note your annual contribution totals $520.
Direct Transfer Payment Frequency*

Weekly payment of $10Fortnightly payment of $20Monthly payment of $43Yearly upfront payment of $520
Direct Transfer Payment Date*

DayMonthYear
This is the date that your recurring payment will happen.
ACCEPTANCE*

I agree that I have read, understood and accept the Friends With Benefits Terms & Conditions (available under the Make A Donation section of our website).I agree that I have read, understood and accept Neuromuscular WA's policy privacy (available at the bottom of all our website pages).
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Friends With Benefits Membership Form