Living My Way Membership Enquiry Form

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* 1. Full Name:

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* 2. Postcode:

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* 3. Contact Person's Name

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* 4. Best Contact Number:

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* 5. Email Address:

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* 6. Preferred Method of Contact:

Phone Call

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* 7. What is the most suitable time to contact you?

	Monday	Tuesday	Wednesday	Thursday	Friday
AM	AM Monday	AM Tuesday	AM Wednesday	AM Thursday	AM Friday
PM	PM Monday	PM Tuesday	PM Wednesday	PM Thursday	PM Friday

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* 8. Do you have any special requirements in regards to communications

Yes

If yes, please specify what your requirements are Larger font, colour, size, do you require an interpreter?

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* 9. Are you Aboriginal or Torres Strait Islander

Yes

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* 10. Please state the nature of your disability:

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* 11. Please select funding type from the list below

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* 12. How is your funding managed

Plan Managed

NDIA Managed

Self Managed

Combination

Unsure

Other (please specify)

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* 13. What services are you interested in?

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* 14. How did you hear about Living My Way?

Website

Member Referral

Facebook Page

Office Signage

Living My Way Flyer

NDIS

LAC

Other (please specify)

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* 1. Full Name:

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* 2. Postcode:

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* 3. Contact Person's Name

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* 4. Best Contact Number:

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* 5. Email Address:

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* 6. Preferred Method of Contact:

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* 7. What is the most suitable time to contact you?

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* 8. Do you have any special requirements in regards to communications

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* 9. Are you Aboriginal or Torres Strait Islander

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* 10. Please state the nature of your disability:

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* 11. Please select funding type from the list below

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* 12. How is your﻿ funding managed

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* 13. What services are you interested in?

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* 14. How did you hear about Living My Way?

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* 15. Any additional Information or any questions, please list below:

* 12. How is your funding managed