Membership Form

Membership Form

This form provides us with important information that we need to operate our Friendship Centres and Activities. Your information is held in accordance with Data Protection laws and will not be passed on to third parties.
Name of Member:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email Address*
example@example.com
Phone:

Home Phone numberMobile Phone Number
Residential Address*

Street Address

Street Address Line 2

CityState

Post Code
Living Arrangements

Live AloneWith Partner/Family/Whanau/FriendResidential CareRetirement VillageOther

Emergency Contact Information:*

	Full Name	Contact Number
Emergency Contact 1
Family member contact

Details of any needs (e.g. allergies, intolerances, medical conditions, disability, developmental delays):
If none, please leave blank.
What, if any, interests do you have ?
(optional)
Total Mobility Card
Transport arrangement requirements - If not TM Card, one can be organised with a Communicare Assessor (There is a cost involved)
I acknowledge that all photographs/film taken during activities held at Communicare or on outings arranged by Communicare remain the property of Communicare and may be used in promotional materials.*
How did you hear about Communicare- If from a member of Communicare please state name.
While all practicable care will be taken, personal belongings will remain the responsibility of the member (or their carer).

I confirm that this information is correct, and may be kept on file and used for my benefit to contact health professionals, next of kin or caregiver, as necessary.

The information will only be accessed by Communicare staff and volunteers for the sole purpose of the delivery of Communicare services. I understand that data will be held securely and will not be distributed to third parties.

I have a right to change or access information. I understand that when this information is no longer required for this purpose, Communicare will dispose of all information.

I confirm that I am 65 years or older (or less dependent upon circumstances)

Living in own home(Living independently) or with family but on own during the day; or in Retirement complex; or in Pensioner housing/Social housing or care facility

I am able to interact socially with others

I am able to participate in our programmes

I am independent with toileting and feeding

Communicare will provide lunch and morning tea at all centres that reflect the nutritional requirements of members as best as possible. Communicare does not provide transport but will assist in making arrangements through paid services where possible and practicable.

Current charges are as follows:

$6.00 per session (this is a contribution towards expenses to run the group)

Membership of $30.00 per annum is payable on joining. I understand I am able to visit any group within Communicare with this membership

Communicare guests will pay for any additional services, e.g. outings with prior notice. Every effort will be made to keep the cost of such outings at a reasonable level. Members will not be required to attend these sessions if they choose not to.

Each member is responsible for the safety, security and insurance cover of their own personal belongings, but Communicare will exercise due care and comply with relevant laws.

Communicare policies and procedures cover staffing, safety and emergency management to safeguard guests, staff and volunteers. Please ask if you would like to see a copy of our policies.

If you wish to make a complaint about our service please talk to the centre coordinator in the first instance. If further information is required call the Support Office and talk to the General Manager.
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