Your Blue Book is published by Retina New Zealand Inc. RETINA NZ FIGHTING BLINDNESS 0800 233 833 04 299 1801 PO Box 2232 Raumati Beach Paraparaumu 5255 retina@retina.org.nz www.retina.org.nz Retina New Zealand Inc. would like to acknowledge the financial assistance from; • Royal New Zealand Foundation Of The Blind • New Zealand Lottery Grants Board We thank you for your support on this project and our other important peer support and public awareness projects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(Mr/Mrs/Miss/Ms/Dr) (First name) ......................………………… (Surname) ADDRESS: ....................................................................................................... ......................................................... POST CODE ...................... PHONE: Home: (0 ) .............................. Work: (0 ) ........................... EMAIL: ............................................................. Mobile: ................................. YEAR OF BIRTH: ....................... For statistical purposes OCCUPATION: ................................................................................................ MEMBERSHIP SUBSCRIPTIONS: Waged: Unwaged/Retired $20.00 $10.00 Donation: Retina NZ - Members’ Services $…………… Donation: Retina NZ - Research $................. Total Payment $................. All donations over $5.00 are tax deductible. (A receipt will be issued.) There are three ways to pay your annual subscription. Please circle one: 1. By telephone banking or on-line bank transfer, the bank account number for payments to go into is: 12-3013-0845604-00. Please put your initials & surname in the reference column so that we can easily identify your payment. 2. Go into your local ASB branch with this form and pay cash into the account number quoted above. Please put your initials & surname in the reference column so that we can easily identify your payment. 3. Send us a cheque with the completed application form. (When paid this form becomes a Tax Invoice – G.S.T. No. 53-686-885) How do you want to receive your newsletter PRINT / CD / EMAIL? (Please circle applicable format(s) Are you a member of the Foundation of the Blind? YES / NO SIGNED ............................................................ DATE ................................. Retina NZ has a database showing the type of macular and retinal conditions that our members have. We ask that new members complete the Database Information Form. The information in this form will be securely stored on the data information file. It will only be released to or accessed by Society office holders to enable these persons to do their work. Organisers of local meetings will only have access to the contact details of people in their local area. Database Information Form My diagnosed eye condition is: ................................................... Please tick in the brackets on the left hand side of the page if any of this information applies to you. ( ) I am a parent of a child/young adult with a retinal or macular condition (State what) ........................................................................... ( ) I am the partner/sibling/ friend of someone with a retinal or macular condition (State what) ............................................................................ ( ) I am an ophthalmologist ( ) I am an optometrist ( ) I am a scientist ( ) I am a healthcare or RNZFB professional Important Phone Numbers Retina NZ …......................................................... 0800 233 833 RNZFB …............................................................. 0800 24 33 33 Your Eye Specialist _________________________________________ Other _____________________________________________________ ___________________________________________________________ ___________________________________________________________ Other publications from Retina New Zealand Inc. • Coping with some sight loss or a degenerative retinal condition. (DL Brochure) • Supporting people with degenerative retinal disorders. (DL Brochure) • Detached Retina – A matter of urgency. (DL Brochure) • Take the Amsler Test – A self test for early detection of Macular Degeneration (A5 Card) We also publish a quarterly newsletter which is available at no cost to members. It is available in print, audio, or via email as a pdf or text file. It serves to keep us informed of research updates, clinical trials and potential treatments, as well as practical advice to help us better understand our eye problems and the challenges that go with it, as well as interesting stories of member's personal experiences. Membership is $20 per year for waged and $10 per year for unwaged or retired. To join simply fill out the application form and post it to us. If you're not sure about something or have any questions, simply give us a quick call on 0800 233 833