Associate Member Application

Associate Membership Qualifying Criteria: *

Please select appropriate criteria, you will not be able to continue with this application without having met any of the criteria listed

I am a spouse or family member

I am the carer of a member

I am vision impaired (A person that is Vision Impaired with corrected visual acuity measured between 6/18 and 6/60, and/or with a visual field loss (and not legally blind))

If you are a family member or spouse or carer of a member, please specify the member's name:

Supporting Document (low vision associate member applicants only)

Please upload a.jpg or .pdf file of Ophthalmologist Vision Report/Letter

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Personal Details

Gender: *

Please make a selection from list

What is your marital status?:

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 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 Associate Member.

Emergency Contacts and Other People

Emergency Contact #1

Relationship to you:

Emergency Contact #2

Relationship to you:

General Practitioner:

Primary Disability (if applicable):

Please select your primary disability from the list

Other Disabilities:

Please select any other disabilities from the list

Please list any other medical conditions:

Please list any allergies:

Covid-19 Vaccination Date: *

Covid-19 Vaccination Status *

Activity Interests

Select your interest in any of the listed activities?

*Transport available (pending availability as priority is placed with full members first)
-15 Km radius of Campbelltown social centre
-25 Km radius of Southern area
-25 Km radius of Northern area

I have been provided with a copy of the current Beyond Blindness Associate Member Policy and agree to abide by the Policy. *

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

Attached is my yearly associate membership fee payment of $25.00

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.