Change Membership Details

Current Membership Category (Please tick appropriate box)*
- Affiliate Member - Support Groups operating in WA
- Associate Member - Not for Profit providers of services to Support Groups and their members
- Allied Member - Support Groups external to WA and/or community organisations that do not qualify as Self Help & Support Groups
- Corporate Member - Businesses operating for profit, educational institutions, government departments and statutory authorities
- Individual Member - Individuals who share and wish to promote and support the philosophies and values of Support Groups
- Life and Honorary Member - Deemed by the Board
Please provide your CURRENT details:
Name of Group / Organisation / Individual*
Group/Organisation Postal Address
- Please tick this box if you would the above address to appear in the ConnectGroups online directory
Group/Organisation Street Address
- Please tick this box if you would the above address to appear in the ConnectGroups online directory
Group/Organisation Contacts
Main Contact Name
Main Contact Email
Main Contact Phone
Contact Name 2
Contact Phone 2
Contact Email 2
Contact Name 3
Contact Phone 3
Contact Email 3
Please list any contacts/details that are NO LONGER CURRENT:
Other Contact Details
Fax
Freecall
Email*
Website
Description of Support Group Services
Description of the group/organisation’s services:
SERVICES - Please tick which service/s your group provides:
- 24 Hour Services
- Advocacy
- Audio Visual Material
- Brochures/Posters
- Clinical Services
- Counselling
- Educational Services
- Facilities for Non-English Speaking People
- Free Advice
- Group Meetings
- Home Visits
- Information Services
- Legal Information
- Liaison with Govt Depts
- Library Resources
- Newsletter
- Professional Services
- Rehabilitation
- Research
- Self Help/Support/Fellowship
- Training Workshops/Seminars
- Other (please describe below)
Other (please describe)
SUBJECT INDEX - Please tick the subject box/es that are most relevant to your group:
- Addictions
- Aged/Seniors
- CaLD
- Carers
- Chronic Conditions
- Disability
- General Health
- Genetic Conditions
- Grief and Loss
- Mental Health
- Trauma
- Youth
Other (please describe)
Form completed by
Position

ConnectGroups - Change Membership Details

Please provide your CURRENT details:

Group/Organisation Contacts

Other Contact Details

Description of Support Group Services