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Membership Application: Introductory Subscription


Part 1: Member Contact Details
HoH Memberships include parents and their children. (Inclusion of children is this registration is optional). In the case of 'financial members', both parents have voting rights if their names are entered in the register. One member should be nominated as the primary member to whom notices and other communications will be addressed to.
	Primary Member	Spouse/Partner
First Name
Last Name

Email

Telephone		Mobile
	eg. [04] 0000-0000	eg. [0400] 000-000
Note: Members outside of Australia should also include country/area codes. Telephone numbers will NOT be published unless you have consented (below) to be added to the Family Contact list. We do however need these details to confirm your membership.
Address	Street Note: address will not be published	Suburb, Town or City
		Post Code:
Region		Specify Country and State below if not listed in the drop list
Country
State	State, Province, County or Local Region

Part 2: Member Options

Login A Login consisting of the primary member's first and last name (JohnSmith) is automatically generated when you submit this form. An email confirming your registration and your Login/Password will be sent to the email address you provided above.

Member Group Please select a membership group to help us tailor Hearts of Hope Australia website content and services to best suit your needs

News Would you like information about Hearts of Hope Australia (website updates and other news) to be emailed to you? Yes

Family Contact Do you want to be included on the Family contact list?
Note: If you select Yes, your phone number will be be published so that families that require support are able to contact you. YesNo

Notices From time to time, HoH sends information to financial members regarding Company activities (e.g. financial statements, AGM notices etc). The most effective way to do this is via email However, we do understand that this may not be suitable for all members. If you would like these notices delivered by regular mail please replace the statement below with your current mailing address.

Referred By

Please let us know how you found out about Hearts of Hope Australia.

Part 3: Other Member Information

The following fields are optional as details you submit will be displayed in the members register. Please do not provide information that you do not want made public.

About Us

Favourite Quote

Homepage

Our Child

Name Gender:

Birth Date

Medical Details

Which CHD does your child have and when was it diagnosed?

Description of CHD Diagnosed at age

Diagnosed in-utero

Surgeries and Procedures

What medical treatment has your child received, or will your child receive in the near future, at which hospital?

Treatment Details
Hospital

Staged Palliation (Norwood) History
Please indicate which procedures your child has had to date and at what age.

Stage 1 age: eg. 5 days

Stage 2 age: eg. 14 weeks

Stage 3 age: eg. 24 mnths

; Other Surgeries/Procedures

Other Comments :

Note: Comments entered below will not be published

Check the radio button to confirm your intention to register for an Introductory membership... then click REGISTER:

Note: Introductory subscriptions expire when your child reaches 6 months of age. Your membership will revert to a Complimentary subscription at this time. An invitation to become a financial member of Hearts of Hope Australia will be sent to you before your introductory subscription expires so that you continue to access all HoH services.

About Us

Members


	Hearts of Hope Australia Limited (ABN 70 110 635 517) 39 Crystal Downs Drive Blackmans Bay TAS 7052