Queensland Wildlife Rehabilitation Council

Membership Application

This Application form is for new memberships and membership renewals

A new form is required each membership (calendar) year to validate your insurance cover.
Applications received after 1 October each year expire 31 December of following year.

Please complete all details that are marked required. (ONLY ONE PERSON PER APPLICATION. Minimum age of applicant is 15 years of age).

Payment details are at the bottom of form.

Please choose the type of membership required in the dropdown box

Please enter your current membership number

First Name (required)

Surname Name (required)

Date of Birth (required)

Must be over 15 years of age to become a member

Residential Address (required)

Suburb (required)

Postcode (required)

Postal Address or PO Box (if different)

Suburb

Postcode

Best Phone Number (required)

Alternative Phone Number (optional)

Your email address (required)

Please confirm your email (required)

Group Name (if applicable)

Are you currently a registered independent permit holder? (required)
YesNo

Are you currently an active member of the group mentioned above rehabilitating under the group's permit? (required)
YesNo

All personal details will be held securely by QWRC committee, and will not be distributed to other members without permission, nor sold or used for any purposes outside of QWRC business.

Virtual signature

Please check this box, and in doing so you are agreeing to virtually sign this form and to confirm you are the above person. (required)

Date

Please leave this field empty.

Annual (1Jan-31Dec) Membership AU$25.00
Make payment by Direct Deposit to the QWRC bank account at Westpac.
BSB No 034-063 Account number 549477
Please use your surname as a reference for this transaction.
Membership and renewals will only be processed once payment has been verified. (You will receive a email once the process is complete).

Please enter the same reference (Surname) you used for your QWRC membership application fee transaction OR if your group has paid your QWRC membership fee on your behalf then please enter the reference provided to you by your group.
Reference (required. see above note)

A new form is required each membership (calendar) year to validate your insurance cover.
Applications received after 1 October each year expire 31 December of following year.

Once submitted you should receive an automated email to confirm it has been submitted. Please note: We are a small team on the committee and we aren't able to process the memberships instantly so please allow us up to a week for processing.

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Queensland Wildlife Rehabilitation Council

Membership Application

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