Would you like to become a member?

Membership Costs

$22 - Group
$22 - Family/Individual
$22 - Professional/Service Provider
$11 - Concession
No charge - Mailing list only

Simply complete the form below, submit for printing and then fax or post it to us along with your payment. Cheques should be made payable to Victorian Clinical Genetics Services.
NB: All fields marked with * are compulsory fields.

Organization Name:
(if applicable)

Membership Type: *

Title:

Surname: *

First Name: *

Position:

Address:

Suburb:

Postcode:

State:

Work Phone:

Home Phone:

Mobile:

Fax:

Email:

Website:

May we add your email address to our mailing list to reduce the number of paper mailouts we need to send?

Yes
No

We are often contacted by families and health professionals looking for information or supprt regarding a particular condition. Would you be prepared to be a contact for a specific condition(s)? If so, which one(s)?

I am happy for you to pass on my contact details when appropriate

I would prefer you to contact me first before giving out my details

Do you have any comments/feedback for the GSNV that you would like to make?