Life Member Application v1.3 5.7.23

I wish to apply for membership to Beyond Blindness and I qualify for membership as one of the following:(Please upload supporting document below) *

Please select appropriate from the list and note that you will not be able to continue with this application without meeting the criteria

I am legally blind within the terms of a statute of the Government of Australia

I have been a resident in S.A. for at least 12 months

I hold a report from a legally qualified ophthalmic specialist or optometrist attesting that I am legally blind

I hold a Travel Pass for a Person with Vision Impairment (South Australia)

I receive a Disability Support Pension for the Blind or Aged Pension for the Blind

Supporting Document: *

Please upload a .jpg or .pdf file of either:
DSP BLIND concession card,

Travel Pass for the Vision Impaired, or

Vision Report/Letter from an Ophthalmologist or Optometrist confirming you are legally blind

Wait..

Personal Details

Gender *

Please make a selection from list

Do you identify as: *

Please select your indigenous identity from list

Date of Birth: *

Country of Birth: *

Main Language spoken at home:

Would you require an Interpreter? *

Please select appropriate response from list

Not stated

Yes (for non spoken communication)

Yes (for spoken language other than English)

Do you have a guardian?: *

Yes

What is your marital status?:

What are your living arrangements?: *

Please select your living arrangements from list

Do you have Full Ambulance Cover?: *

Yes

Please note:
In the case of a medical emergency, an ambulance will be called. Ambulance costs shall be the responsibility of the Life Member.

Emergency Contacts and Other People

Emergency Contact #1

Mobile: (nnnn nnn nnn)

Telephone: (nnnn nnnn)

Relationship to you:

Emergency Contact #2

Mobile: (nnnn nnn nnn)

Telephone: (nnnn nnnn)

Relationship to you:

Orientation and Mobility information *

Please select all that apply

I am independent - no sight guide or orientation equipment used

I have a guide dog

I require 1:1 Sight guide

I use a long cane regularly

I use an ID cane only

I use mobility equipment - walker

I use mobility equipment - wheelchair

I use public transport independently

Unknown

Eye Condition/Diagnosis

Medical Conditions that may limit your participation in social activities

Please list any other medical conditions that may limit your participation in social activities

Do you have any disabilities other than vision impairment?

Select all that apply

Do you require Wheelchair Access?

Please list any allergies you have:

Covid-19 Vaccination Status: *

Covid-19 Vaccination Date: *

If unvaccinated enter 01/01/01

Assistance Requirements

What assistance would you like?: *

Please select from list any assistance you would like to ahve

Advocacy Support & External organisation referral

Financial Assistance - (qualifying & eligibility criteria may apply)

Occasional Transport to medical appointments (one week notice required) /

Social Support

What is your main source of income?: *

Please select the main source of income from the list

Do you receive individual funding or other govenment assistance? *

Please select all forms of individual funding that you receive

My Aged Care

National Disability Insurance Scheme (NDIS)

Unknown

I request that any information provided to me by Beyond Blindness be provided in: *

How would you like to receive communications from Beyond Blindness (ie newsletter)

Referral Agency Details *

How did you hear about us? Select all that apply

Other Referral Agency Details:

If none of the above - please indicate how you heard about Beyond Blindness

Privacy and Confidentiality

Consent to Obtain/Release information

Information collected by Beyond Blindness is for the purpose of providing you with the most appropriate services. On occasions it may be necessary to pass selected information on to other organisations in order to ensure your service needs are met. In accordance with the Privacy Act (1988), Beyond Blindness is required to obtain consent from you to allow us to do this. You are able to withdraw your consent at any time.

Privacy & Confidentiality - Obtain/Release Information Consent *

Select all applicable for consent

Consent to Take/Release photos/videos

I give consent to Beyond Blindness publishing photographs/images taken of me for the purpose of providing an agreed service and/or for media publications for promotional purposes deemed appropriate by the organisation.

I understand my rights with regards to Privacy and Confidentiality, and give consent to the collection, use and disclosure of my image/videos, as outlined above.

Do you provide consent? *

Yes

Consent for Beyond Blindness to retain photo identification of member

I give consent to Beyond Blindness to retain a photo of me on their database only for identification purposes.

File upload - Photo Identification

Please upload a .jpg image (passport style size preferred) of you or a photo of any other form of photo identification.

Wait..

Membership Fee - $25.00

I agree to make an immediate payment of $25.00 once my membership application is approved and staff have contacted me seeking payment.

Member Signature:

Thank you for taking the time to provide the information in this membership application. A staff member will be in contact with you in the next seven (7) business days to discuss your membership options.