Membership & Renewal Form - Adults with CF

MEMBERSHIP APPLICATION & RENEWAL FORM

FOR ADULTS WITH CYSTIC FIBROSIS
Please tell us the status of your membership*

I am renewing my membershipI am a new memberI have just turned 18 and am transferring from my parent/carer's membership to my own as an adult
Name of Person with CF*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Membership of Cystic Fibrosis Tasmania for Adults and Children with CF is only available to people permanently living in Tasmania - but exceptions will apply for those who have temporarily relocated interstate for study or medical reasons. CFT reserves the right to ask for proof of residence or temporary relocation.
Is Tasmania your principal place of residence? This means where you live the majority of the time.*

YesNoI am temporarily living interstate to study but into to return to Tasmania when I have finished studying.I am temporarily living interstate for medical treatment (such as surgery, treatment or organ transplant) but intend to return to Tasmania when I am permitted to.
Email*

Confirmation Emailexample@example.com
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemaleNon-Binary
Mobile Number*
Employment Status
Please select from drop down
Name of Workplace/School etc
Optional
Name of Emergency Contact*

Name

Street Address Line 2

Relationship

Mobile Number
Which CF Clinic do you normally attend?
Eg RHH, LGH etc.
If you are an adult with CF, do you have any children?
If so, how many?
Any information that you provide to CFT will be kept confidential. This question is optional. So that we can provide you with the relevant support services that you may need, please let us know if you are impacted by any of the following:
Health issues

CF Related DiabetesMental HealthCoeliac DiseaseOsteoporosisLiver or Kidney issuesPancreatic InsufficiencyOther
Other issues

Financial challengesHousingLack of support networksI identify as "neuro diverse" and may require some additional support or advocacyOther
How many years do you wish to join or renew your membership for?*
CFT e-NEWS

We regularly send out e-newsletters that aim to keep our members and supporters informed about our activities, such as advocacy, fundraising events, helpful tips on managing CF and research updates.

As a member, you will be automatically added to our email list. It may also be useful for other family members or loved ones to receive this information. These could include siblings, partners, grandparents or friends.

If you would like others to receive the newsletters, please list them below. This is useful, especially if they do not follow our social media pages. (They will be able to unsubscribe at any time if they no longer wish to be on the list)

PLEASE ADD THE FOLLOWING PEOPLE TO THE MAILING LIST TO RECEIVE CFT e-NEWS
CFT E-NEWS - ADDITIONAL PERSON 1
Name of Person to be added to CFT e-News List
Name
Email address of person to be added to CFT e-News List
Email address
Relationship to Person with CF
Relationship
CFT E-NEWS - ADDITIONAL PERSON 2
Name of Person to be added to CFT e-News List
Name
Email address of person to be added to CFT e-News List
Email address
Relationship to Person with CF
Relationship
PRIVACY

Privacy laws prevent us from disclosing your information to any third parties such as the CF Clinics and Hospitals. This may hinder our ability to maintain our records and prevent us from offering available support when it may be required.

Do you give permission for your information to be provided to third parties for the following purposes such as:

- Verifying membership status;

- Identifying equipment you have on loan or may require;

- Maintaining currency of contact details; and

- Offering support services when they may be required.
Do you give CFT this permission as outlined above?*

YesNo
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.

I also understand that under CFT's Membership Policy, my membership may be cancelled if Tasmania ceases to be my principal place of residence for any reason other than study or medical reasons.
E-Signature Name*
Date*

DayMonthYear
Date

Membership Renewal*

1 Year Membership Renewal: $30Renew your membership for one year.

$30AUD

3 Year Membership RenewalSave $10 by renewing your membership for three years.

$80AUD

5 Year Membership Renewal: $120 Product Image

5 Year Membership Renewal: $120Save $30 by renewing your membership for five years

$120AUD

Total

$0.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature

Clear
Should be Empty:

MEMBERSHIP APPLICATION & RENEWAL FORM

CFT e-NEWS

CFT E-NEWS - ADDITIONAL PERSON 1

CFT E-NEWS - ADDITIONAL PERSON 2

PRIVACY