**2008 AICAFMHA MEMBERSHIP**
for the year 1 July 2007 to 30 June 2008.
Supporting infant, child & adolescent mental health.

  

Please PRINT THIS FORM, complete the  details, and send it to:
AICAFMHA, PO Box 387, STEPNEY SA 5069

All information supplied on this form will be kept confidential. The Association may from time to time release the name and contact phone number of members to people for professional purposes only. If you would prefer that none of your contact information is released, please indicate this below.

r    I do not consent to the release of any of my contact details for any purpose.

Please complete using your preferred contact details.

Name (incl title):                                                                                         

Position:                                                                                                      

Organisation:                                                                                             

Address:                                                                                                     

                                                                                              

                                                                                              

State                                       Postcode                                 

Phone:                                                     Fax:                                               

* Email:                                                                                                        

r   I am a member of an AICAFMHA email list
r   Please send me an email invitation to join the AICAFMHA News list

 

 

ORGANISATIONAL STATUS
Information supplied in this section will help AICAFMHA identify
the range of organisations the association represents.

r Consumer/carer/young person
r Professional

Professionals, please indicate one of the following:
GOVERNMENT
r Hospital (Health)             r Community (Health)
r Education
r Youth Services
r Justice
r Family Services

NON-GOVERNMENT
r Health
r Education
r Welfare Services

OTHER
r Student              r Not currently employed
r None of above:                                        

SPECIAL INTERESTS
AICAFMHA is planning a range of special interest discussion
groups. Please indicate your interest in the following:

r Rural / Remote Services
r Inpatient / Day Programs
r Consumer / Carer Partnerships
r Indigenous Issues
r Mental Health Promotion
r Children of Parents Affected by a
Mental Illness
r Service Provision and Policy
Development Issues

MEMBERSHIP FEES for the year to 30 June 2008.
Consumer/carer/young person/student
$22.00
(inc GST)		 Professionals
$49.50
(inc GST)		 Organisations
$99.00
(inc GST)

PAYMENT DETAILS
To: Australian Infant, Child, Adolescent & Family Mental Health Association Ltd PO Box 387, Stepney, South Australia  5069

Enclosed is my:  r Cheque
                          r Money order
(payable to AICAFMHA Ltd)

OR

Charge to my:  
r Visa
r Mastercard
r Bankcard

Please charge my account with the amount of
$                                   for AICAFMHA membership.

Full name on card:                                                                   

Card number: _  _  _  _  -  _  _  _  _  -   _  _  _  _  -  _  _  _  _

Valid from:          /                    Expiry date:           /           

Signature of cardholder:                                                            

Applications made using credit card payment may be faxed to: 08 8132 0787.