Online Membership Application

Apply for your Parkinson's ACT Membership online.

Membership Application

New member or renewing?(Required)

Membership number

Don't worry if you can't find it!

Membership can include a partner, relative or friend.

Pleas nominate as the member, the person you would like PACT to communicate with using the mailing address and phone numbers below.

Member Information

Name(Required)

Title First Last

Role(Required)

Email address of member(Required)

Enter Email Confirm Email

Mailing Address(Required)

Phone

Mobile

Member's Parkinson's Information

Age diagnosed with Parkinson's

Year of Birth

Are you still working?

Co-Member Information

Would you like to include a co-member in your application?

Yes

Name(Required)

Title First Last

Role(Required)

Email of Co-member(Required)

Enter Email Confirm Email

Co-Member's Parkinson's Information

Age diagnosed with Parkinson's

Year of Birth

Are you still working?

Membership Details

Would you like to indicate if you are willing to volunteer to help with

Organising support group

Events

Serving on the committee

Choose membership period(Required)

Membership fees are for the financial year (ending June 30th). Payment is a second step after submitting the form.

Choose a payment method for membership fee(Required)

The completed form and instructions for your payment selection will be emailed to you immediately upon submission.

Comments or Feedback

Consent(Required)

I have read, understood, and accepted the privacy policy.

Your information will not be shared with any other entity without your permission and will only be used for Parkinson's ACT to contact you.

Find our Privacy Policy via the link in the website footer.

Name

This field is for validation purposes and should be left unchanged.

Online Membership Application

Membership Application

Member Information

Member's Parkinson's Information

Co-Member Information

Co-Member's Parkinson's Information

Membership Details

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