Membership Application
Prefix:
* First Name:
Middle Name:
* Last Name:
Gender
* Address:
Suburb:
* City:
* Region
* Postcode
Home Phone:
Mobile:
Other Phone:
Email Address:
Email Address - other:
Type of Impairment Hearing
Low Vision / Blind
Mobility
Learning
Psychological / Mental Health
Other
Physical
Access Requirement
Ethnicity
* Preferred Contact Method Email
Phone
Post
Text
Preferred Format for Publications
Topics of Interest Pacific
Maori
Youth
Older People
Convention of the Rights of Persons with Disability
Housing
Transport
Employment/Economic Development
Education
Health
Access to build environments
Accessible infomation
* Membership: Individual (Waged)
Individual (Unwaged)
Family Membership
Associate (unwaged)
Associate (waged)
Computer Access
Internet Access
Do you have a cell phone
How do you prefer to receive information from DPA? Hard copy of newsletters
Email
Text
Website
Facebook
Are you interested in providing input to the work DPA does?
If yes, how do you wish to be contacted for information? Email
Text
Phone
Website
Facebook
* Code of Conduct Acceptance As a member of DPA, respectfulness will be evident in all interactions associated with DPA. Business related to DPA will follow the DPA constitution, strategic plan and policies.
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