Annual Membership Fee (Renewable 1st of July each Year)
Concession $11 Support Organisation $22
Family $22 Other Organisation $22
Single $22 (GST Included)
Membership Details/Donations (Donations over $2.00 are tax deductible)
Membership fee cost:$
I wish to make a donation of: $
Total:$
0
Questionaire (not required, but by answering the following we can provide better services. All information remains confidential)
What age is the person affected by epilepsy?
0-5 6-11 12-18 19-30
31-50 51-65 65 plus
What age are you if you are a carer for a person with epilepsy?
12-18 19-30 31-65 65 plus
How would you rate the disorder's impact to the person?
Low 1 2 3 4 5 High
Would you like to know more about:
Deferred Gifts Epilepsy Centre Special Events
Voluntary Help Financially assisting The Epilepsy Centre
Would you like more information about:
Causes of epilepsy Diagnosis Education in schools Employment
Management (Medication, Trigger Factors) Services for people with epilepsy Women with epilepsy Other
