PHOENIX HOUSE MEMBERSHIP FORM
Phoenix House won't sell / distribute your name to any other organisation.
This form can be printed out or you can click on the link below to download a simple text document membership.doc (notepad) then print it, Please send completed forms to the address at the bottom. Thank You.

I would like Membership to Phoenix House as a :

[ ]1. Burn Survivor Member (Burn Survivor) .. .. .. .. FREE
[ ]2. Fire Brigade Member and Volunteers .. .. .. .. .. FREE
[ ]3. Hospital Staff Member. .. .. .. .. .. .. .. .. .. .. .. .. FREE
[ ]4. Ambulance Staff Member .. .. .. .. .. .. .. .. .. .. .. FREE
[ ]5. Police Force Member .. .. .. .. .. .. .. .. .. .. .. .. .. FREE
[ ]6. State Emergency Service Member .. .. .. .. .. .. .. FREE
[ ]7. Associate Member (Families and Friends). .. .. .. $25.00
[ ]8. Students and Pensioners .. .. .. .. .. .. .. .. .. .. .. .. $25.00
[ ]9. Professional Member (Medical and Legal) .. .. .. $100.00
[ ]10. Institutional Member (Companies) . .. .. .. .. .. .. $150.00

Membership Payment assists in the costs associated with running of Phoenix House.

Name : ______________________________________ Address:_____________________________________
City:_______________________
State:______________________
Postcode:________

[]My cheque/money order is enclosed.
(Please make payable to Phoenix House)

Please charge to my:
[]BankCard []Visa []MasterCard []Other ___________
Card Number #:____________________________________
Cardholders Signature:____________________________
Expiration Date:____________
Amount: $________
Contact Telephone Number:________________
Mobile:______________________
Email:________________________________

Post this application form to:
Phoenix House for Burn Survivors
25 Parakeet Street
Macleay Island 4184