C0MMUNITY GROUP Membership Form
All Community Group Memberships are $20.00.
All Membership fees are from January 1 through December 30 for the current year. Community Group Membership was
established by Emerald Community House to build and support community strengthening activities.
Community Group Benefits
Free use of our facilities for the purpose of Community Group meetings
One free advertisement to promote your Group in one of our Term Programs
50% Cardinia Subsidy to Volunteers undertaking certain Courses
Covers membership for participants undertaking courses on behalf of their Community Group
Cross promotion of services
Access to grant applications, partnership possibilities and Council funding opportunities
Would your Community Group be willing to display our Short Term Programs at your facility? Yes
No
Community Group Name ……………………………………………………………………………………………………………………..….
Surname of Applicant ……………………………………………………. First Name …………………………………………….…………….
President’s Name …………………………………………………………Secretary’s Name. ……………………………………………….…
Address .……………………………………………………………………….………………………...Post Code…………..……...…………...
Postal Address (if different) …..……………………………………….....Email Address. ……………………………………………………...
Telephone B/H. …………………………… A/H…………………………Mobile………………………………………………………………….
Payment Details
Cash – In person at 356-358 Belgrave-Gembrook Road, Emerald 3782
Direct Debit: BSB 063 842 Acct 1009 3095, Identify Membership in Description Field
Cheque – made out to Emerald Community House
Credit Card, Visa M/Card Card No .............. …………. …………. …………. Expiry ……../……..
Cardholder Signature ……………………………………………………………………………… ..
Membership $............................. Receipt No…………………….Member Signature ……………………………………………………
This organisation respects your right to Information Privacy. Information we collect and hold on House Members is kept in
accordance with information Privacy Laws. Contact us if you require further information or a copy of the Emerald Community
House Privacy Policy.
Office Use Only
Membership No …………………..... Date ……………… Member’s Database
Member’s Mail-out
Member’s Email
Occasional Care Out of School Hours Care Short Courses Adult Literacy & Numeracy Health & Leisure
PO Box 328 Emerald 3782, 356 Belgrave-Gembrook Road Emerald 3782 Tel 03 5968 3881 Fax 03 5968 6152
Email: emhouse@iinet.net.au www.emeraldcommunityhouse.org.au ABN 43 678 002 985 Incorporated A12381