Please enable JavaScript in your browser to complete this form.Type of membership *QDN Ordinary Member* (a person with a disability) – free to join and has voting rights*** By this application you are applying to be a member of QDN and agree to be bound by its constitution. ** Ordinary members have the right to vote and be Elected Director of the QDN Board. QDN is covered for $20 000 000 in Public Liability insurance.Nominee: I have been nominated for QDN Membership by *A QDN Member (please enter their name below)I would like QDN to contact me for nominationApplications for new QDN membership need a QDN member to nominate them. If you don’t know a QDN member a QDN Director can act as your nominee to support your membership application. Could you please choose one of the options above. If you know a QDN member who can nominate you type their name in the space provided below. If you don’t know a QDN member please choose the second option.My title (Mr, Mrs, Miss) *Name of QDN Member nominating me is *My first name *My last name *My email address (If you do not currently have an email address you can get a free one at https://support.google.com/mail/answer/56256?hl=en – just copy and paste this link into your search engine) *My best phone number *My address (street number and name or PO Box) *Suburb *Postcode *I identify as: *AboriginalTorres Strait IslanderLGBTIQ+ (Lesbian, Gay, Bisexual, Transgender, Intersexual, Queer+)Coming from another cultural backgroundOtherIf Other, please describe:My disability - A description of my disability is: *Intellectual disabilityNeurological disabilityPhysical disabilityLearning disabilitySensory disabilityOther disabilityIf Other, please describe:My areas of interest - Please tick the box/ boxes that you are interested in.NDISRural & RemoteAssistive technologyAgeingIncome support/pensionsAboriginal/Torres Strait IslanderMedical aids and equipmentDigital InclusionEmploymentHuman rightsCulturally & Linguistically diverseAccessibilityEducationHealthCost of livingDisaster recoveryHousingJustice & legal issuesResearchTransportLGBTIQ+EnvironmentOtherIf Other, please describe: (copy)Consent for collection, use and disclosure of personal information *By agreeing to become a member, I authorise and consent to Queenslanders with Disability Network (QDN) to collect, use and disclose personal information for the purposes provided under this form, privacy notice and privacy policy.For our Privacy Policy please go to https://qdn.org.au/privacy/ and for our Member Code of Conduct please go to https://qdn.org.au/membership/member-policies/.PhoneSubmit
