Application For Membership
In order to complete the form, all sections must be filled in! Please contact YSRC if you need guidance on a specific section.
Section 1: Contact Details
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
My Apical Ancestor Is:
Please select as many as required.
*
Ap-barra (Upparawa) and Dharringa
Annie Tira
Biddie (mother of Fred Carnamah)
Billy and Judy Thompson
Brindy / Brinty
Cissie Broad
Eeranyoo
Eliza
Galena
Jane Cotter (mother of Sarah Mabel Bell and Patrick John Bell)
Jane Hunt
Jibjia (Rosie Jones)
John Yuna Councillor
Lizzy Flynn
Mary Gingina
Mary Nundie
Nellie
Noogy (grandmother of Minnie Campbell)
Punch
Rosie Coleman
Sarah Jane Campbell
Sarah Broad
Sarah Feast (Jooldarnoo)
Shilling
Timothy Benjamin
Uanda
Woondoora
Wyoo and Myonada
Rosie (mother of Walter Ninghan)
Section 2: Family Details and Connections
Please provide full names.
Parents
Your Dad's Full Name
*
Your Mum's Full Name
*
Grandparents
Pop (Your Dad's Dad)
Nan (Your Dad's Mum)
Pop (Your Mum's Dad)
*
Nan (Your Mum's Mum)
*
Great-Grandparents
Great-Pop (Your Dad's Pop)
Great-Nan (Your Dad's Nan)
Great-Pop (Your Mum's Pop)
Great-Nan (Your Mum's Nan)
My cultural group connection/s within the Yamatji Nation ILUA Agreement area is:
*
Hutt River
Mullewa Wadjari
Southern Yamatji
Widi Mob
The town / area within the Yamatji Nation ILUA Agreement Area that you most strongly connect to is: (Northampton, Geraldton, etc):
*
I confirm I meet the following eligibility criteria for membership as per Clause 8.1 of the Yamatji Southern Regional Corporation Limited Constitution:
*
I am an individual who is at least 18 years of age AND I am a Yamatji Nation Person.
Please agree to the rules of YSRC:
*
I agree to be bound by the rules of Yamatji Southern Regional Corporation Limited as per Clause 8.3(b)(ii) of the company’s Constitution.
For The Elders Gift Card Program, please confirm:
I confirm I am 60+ years of age this financial year and would like to apply for the ELDERS GIFT CARD program valued at $1000. (NOTE to register you MUST include ID with proof of Date of Birth)
Upload ID with proof of date of birth:
*
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