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Members Only

Aussie Hands Members only.   Application form to register email contact details:

Title: Mr /Mrs /Ms /Dr /Other Please specify:
First name   Surname:

Address

 

City: State: Postcode:
Phone No: (BH):

(AH):

Mobile:

Fax No:

 

Email address:

 

My child has a hand difference

Yes/No

Male / Female

Hand Condition:

Given Name:

Date of Birth: ____ / ____ / ____

_______________________________
I am a parent of a child with a hand difference

Yes/No

 
I am an adult with a hand difference
Yes/No

Male / Female

Hand Condition:
Given Name:

Date of Birth: ____ / ____ / ____

_______________________________

I don't have a hand difference, but I would like to support Aussie Hands as my professional expertise may assist those with a hand difference, eg, Occupational Therapist, Counsellor, Paediatrician, etc.

My profession is __________________________________________________________________________________

Your email address will be displayed in two categories:

(i) Suburb/Town/State (in Australia)

(ii) the name of the hand difference, eg Symbrachydactyly and brief details of the hand difference, Male/Female, Date of Birth

CHECK-LIST

Membership form (attached)
Yes/No
(Membership $10 per annum) cheque to ‘Aussie Hands Foundation' Inc attached
Yes/No
I have completed the ‘talk to other families' application form
Yes/No

I have printed, read and signed the Disclaimer (attached)

Yes/No
I would like to provide an ‘inspirational story' for the website
Yes/No

Send to Aussie Hands, PO Box 8, Coburg, Vic, 3058