Associate Member Application

- Associate Membership Fee: $25.00 per annum (Renewal Fees fall due 1 July each year)

Name: *

First name

Last name

Nickname/Preferred Name:

Address: *

Address line 1

Address line 2

City/Suburb

State/Territory

Postcode

Email address:

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

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 or optometrist Vision Report/Letter

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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 Associate Member.

Emergency Contacts and Other People

Emergency Contact #1

Relationship to you:

Emergency Contact #2

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 your vision impairment?

Please slect all that apply

Do you require Wheelchair Access?

Please list any allergies:

Covid-19 Vaccination Status *

Covid-19 Vaccination Date: *

If unvaccinated enter 01/01/01

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

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.

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Membership Fee - $25.00 annually with renewal due each 1 July

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.