Last name: ……………………………………… Given name/s……………………………………………
Preferred or nickname (eg. Margaret / Meg. Elizabeth / Liz)………………………………..
Address: ……………………………………………………………………… Postcode: …………………
Date of birth:
DD/MM/YYYY …………/…………/………… Note: Min. age for membership is 18 years
Telephone: Home: …………………………… Mobile:………………………….………………………
Email address: …………………………………………………@……………………………………………..
Emergency contact names / relationship / contact number
1. …………………………………………/…………………………………………/…………………………….
2. …………………………………………/…………………………………………/…………………………….
Doctor name / Location-Clinic / Contact number
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Have you any health conditions, or are you on any medication? YES / NO
If YES, please provide brief details.
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How did you get to know about Kyneton Men’s Shed or who introduced you?
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Note: You not entitled to use the Shed’s workshop facilities and equipment until you have completed Shed Induction and Workshop Skill and Safety competence requirements.
Applicant’s Declaration
I will abide by the policies and procedures of Kyneton Men’s Shed (KMS) and act in a safe and respectful manner at all times whilst I am in or at the KMS, utilising its facilities and / or participating in projects or other activities of KMS.
I will have due care and regard to all other patrons whilst in or at KMS or participating in any KMS project or activity.
Applicant’s signature: ………………………………………………………… Date: ……./……./……..
Associate membership fee = $40.00. Fees are payable by direct deposit.
(Associate membership does not include voting rights)
BENDIGO BANK
Account : Kyneton Men’s Shed Inc
BSB : 633 000
Account No. : 195 080 122
Reference : Enter your FIRST INITIAL and LAST NAME, followed by the word DUE.
Payment terms are available. Please contact the Secretary or Treasurer for more details.
Occupation/ Trades/ Skills/ Interests (past or present), including current qualifications/credentials:
…………………………………………………………………………………………………………………………
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Are there any particular activities you would like to do at Kyneton Men’s Shed?
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( ) Tick here if you agree to have your personal contact details disclosed to other Members.
( ) Tick here if you prefer not to receive regular updates or special notifications from KMS.
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OFFICE USE ONLY
Proposer: ……………………………………. Seconder: ………………………………………………
Application received: ………/………/,,,,,,,… Committee approved: ………/………. /……….
Payment received $……………………….. Receipt No: ……………… Date: ……/………/……….
Payment received $……………………….. Receipt No: ………………… Date: ……/………/………
Membership no.: …………………………… …………………………………………………………….
(Members Register) KMS Secretary Date: ……/………/………