APPLICATION FOR MEMBERSHIP Please fill in form BEFORE YOU PRINT Single Full Name *(required) Birth Date Couples Surname *(required) Given Names *(required) Birth Date Address *(required) Suburb *(required) P/Code * Phone Number *(required) Email Address Preferred Name/s (for use at camps) Any medical or physical disability that may restrict you from certain activities? I wish to become a member of COCOA. I have read and understood the conditions of membership and I agree to accept them Signature: Date: Registration and Subscription Fees Single: ($23.00) $8.00 reg + $15.00 annual subscription Couples: ($36.00) $16.00 reg + $20.00 annual subscription Mail your application form along with your cheque or money order to Judy Hampsom 2/598 High Rd Lynwood 6147 (Please do not send cash) You may also pay by bank transfer:- BSB 306 050 Account No 4158583 Bankwest Close
Birth Date
Phone Number *(required)
Email Address
Preferred Name/s (for use at camps)
Any medical or physical disability that may restrict you from certain activities?
Registration and Subscription Fees Single: ($23.00) $8.00 reg + $15.00 annual subscription
Couples: ($36.00) $16.00 reg + $20.00 annual subscription
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