Primary Contact
First Name:	Surname:
Mobile:	Email:

Member Type: Concession Single (Grandparent/Health Care or Carers Card) : $ 50.0 Concession Double (Grandparent/Health Care or Carers Card) : $ 60.0 Family (Single) : $ 65.0 Family (Single, Baby <9mth bonus) : $ 65.0 Family (Double) : $ 75.0 Group / Organisation / Business (Non-Volunteer) : $ 300.0 Group / Organisation (Volunteer) : $ 100.0 Gift Voucher ONLY - Trial 1 Term : $ 0.0 Community Volunteer : $ 0.0

LOTE: Other

Address:
Suburb Armstrong Creek Belmont Breakwater Charlemont Corio Geelong Geelong West Grovedale Hamlyn Heights Herne Hill Highton Lara Marshall Moriac Mount Duneed Newcomb Newtown Norlane South Geelong St Albans Park Thomson Torquay Wandana Heights Waurn Ponds Winchelsea Other or not listed
Pcode	State:

ID Card and number: (Drivers Licence Number, medicare card):

How did you find us?: Event/Market Friend GEELONG CIRCULAR LIVING CHALLENGE Gift Voucher Member Referral Neighbour Other Playgroup Previous Member Social Media visit to Grovedale Children's Hub website

How can you help? (select more than one) Toy Purchasing and Processing Fundraising and Events Marketing and Communications Distributing posters to community businesses Administration and Finance Website and IT Support I want to help but I`m not sure how! Please contact me Toy Repair & Maintenance Sewing Graphic Design Photography /videography Clear

Conditions of membership

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Code of Conduct and Child Safe Policy.

By clicking yes I agree to the child safe policy at all times:

WAIVER, RELEASE AND INDEMNITY FOR BICYCLES AND SCOOTERS

By clicking Yes I agree to the Helmet waiver, release and Indemnity for Bicycles and scooters.