Your details

Austprem Inc. is required to collect name and address information in order to keep an accurate register of our members; a necessary part of being an Incorporated Association.

Name               

Address           

Suburb            

State               Please select ACT NSW NT QLD SA TAS VIC WA

Postcode         

Phone              

Mobile              

Email Address

I apply to join Austprem Inc. and agree to abide by the Rules and Guidelines of the Association

Cost per year  $ FREE

I would like to make a donation to Austprem of
$20 $50 $100 Other:         

Donations $2 and over are tax deductible. Please use the Paymate option (link opens in new page) or make a cheque out to Austprem Inc. and forward with your name and address to:
Austprem Inc.
P.O. Box 2157
Sunbury VIC 3429
A receipt will be posted to you

Children's details (please include details of your full term children too, if you wish):

First child's name      
Gender                         Female Male
Date of Birth               
Gestation                    
Weight                         
Hospital                      

Second child's name 
Gender                        Female Male
Date of Birth               
Gestation                    
Weight                         
Hospital                      

Third child's name     
Gender                       Female Male
Date of Birth              
Gestation                   
Weight                        
Hospital                     

Fourth child's name  
Gender                       Female Male
Date of Birth              
Gestation                   
Weight                        
Hospital                     

If you need more space, please add further details in the Introduction area below

Parents' Names

Permissions

I give permission for you to add my child's/children's first name, date of birth and gestation to the Austprem Superheroes birthdays page on the Austprem web site

I give permission for you to include my child's/children's first name and age in the Birthdays column of Austprem Ink (Austprem's Newsletter)

My baby is still in hospital, please enter me in the monthly draw to win an "earlybirds" gift set valued at $69.95. If I win, Austprem has permission to pass my contact details on to "earlybirds" so that colour, size and delivery of my prize can be organised.

A brief introduction mentioning your interest in Austprem:

How did you find out about Austprem?

search engine
from a friend
Austprem brochure
hospital
child health nurse
Austprem Ink Newsletter
Nursery News Newsletter
earlybirds
other (please specify)

   

All personal information provided to Austprem Inc. will remain confidential and will not be used for any other purpose or passed onto any third party without your prior permission.