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 which evidences that I am legally blind /

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

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

Supporting Document: *

Please upload a .jpg or .pdf file of either:
DSP BLIND concession card; or
Travel Pass for the Vision Impaired; or
Ophthalmologist Vision Report/Letter

Wait..

Attached is my life membership fee payment of $25.00

Telephone Number: (nnnn nnnn)

Mobile Number: (nnnn nnn nnn)

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:

Carer Availability: *

Please indicate if you have a carer here

Has a Carer

Has No Carer

Not stated/Inadequately described

Carer Contact Number:

Carer Age Group:

Please select from list

Primary Disability: *

Please select your primary disability from the list

Other Disabilities:

Please select any other disabilities from the list

Please list any other medical details:

Please list any allergies you have:

Covid-19 Vaccination Status: *

Please provide evidence of Covid-19 Vaccination Status

Covid-19 Vaccination Date: *

Assistance Requirements

What assistance would you like?: *

Please select from list any assistance you would like to ahve

Advocacy Support /

External Referral /

Home Visits /

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

Personal Loan /

Shopping Assistance /

Special Purpose Fund (qualifying period applies) /

To link up with BB/RSB Recreation & Leisure Groups /

Activity Interests:

Would you be interested in any of the listed activities?

*Transport available (pending availability)
-15 Km radius of Campbelltown social centre
-25 Km radius of Southern area
-25 Km radius of Northern area

What is your main source of income?: *

Please select the main source of income from the list

Do you receive individual funding?: *

Do you receive a government pension/benefit?:

Please select any applicable from the list

Pension Number: (nnn nnn nnnC)

Please provide Pension number (if applicable)

NDIS Number:

Please provide NDIS number (if applicable)

Transport Pass Number:

Please provide transport pass number (if applicable)

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)

Email address:

If you wish to receive communications from Beyond Blindness via email, please provide email details

Referral Agency Details

How did you hear about us? Select all that apply

Other Referral Agency Details:

Consent to Obtain/Release information
(Privacy and Confidentiality)

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

I understand my rights with regard to Privacy and Confidentiality and consent to have information about me provided to the above organisations for the sole purpose of my welfare. (Members are able to access their file at any time by making an appointment with the Member Services Coordinator. Should another person wish to view a member's file, they must provide written and signed consent from the member prior to the appointment).

Consent to Take/release photos/videos

(Privacy and Confidentiality)

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.