/ 6.4.1 MCH
2016 – 2017
Application ForMembership / 22 Qualtrough Street
Woolloongabba
QLD, 4102
PH: 3391 8122

Please ensure you provide all the details as requested.

Name: / DOB:
Address:
Home PH: / Mob PH:
Email:
My Aged Care Reference /AC Number
(If known)
 / Part Pension /  / Full Pension /  / Self-Funded Retiree / Pension Type: ______

Please tick whichAnnualMembership Fee you are applying for:

 / $10 (does not include postage for Newsletter) /  / $20.00 (includes postage for newsletter)

Please tell us about other services you receive from the Commonwealth Government/ private business and who provides them:

Item / Provider
 / Cleaning (Domestic Assistance)
 / Personal Care
 / Gardening
 / Shopping
 / Home Assist
 / Meals on Wheels
 / Transport
 / Transition Care
 / Package Level: ______

I would like to undertake and accept the following services: (please tick the service/s)

 / Monday Venturers /  / Quilling
 / Wednesday Venturers /  / Tai Chi
 / Thursday Hub Day /  / Aqua Aerobics
 / Feel Good Friday – Exercises to Music (Health screening required) /  / Broadband for Seniors
 / Feel Good Friday – Activities /  / Gentle Yoga
 / Management Committee /  / Volunteering

What are your goals for attending MCH activities?

I understand that: (please tick each one)

 / Fees for each service is paid in cash on the day /  / I must give consent for referrals to be made to another agency
 / All my information is kept private and confidential /  / I have the right to withdraw my consent for referrals at any time
 / I may access information kept about me at any time /  / I have the right to refuse a service at any time without affecting my right to access services at MCH
 / Non-identifying data about services I use is reported for contractual purposes to funding bodies /  / If I am not feeling well it is my responsibility to inform staff of my inability to attend
 / I am responsible to provide a medical clearance if there are major changes to my health or any health issues /  / I have the right for an advocate to speak on my behalf on service delivery issues with MCH staff if required

I hereby waive the Metro Community Hub, its staff, volunteers and Committee Members from any liability of injury that may result from using exercise equipment or participating in activities within the centre and on all outings.

I understand that I am solely responsible for my health and safety, and I acknowledge that I am physically capable of participating in activities, outings and using exercise equipment.

I acknowledge that I understand the waiver described in this document. This waiver is made to the maximum extent possible under law. I acknowledge that I have signed this document under my own free will.

Signed: / Date:
Nominated by: / Name: / Signature:
Seconded by: / Name: / Signature:
Approved by Management Committee by:

6.4.1. New Membership Form 2016/17 1805 V2.2