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 byA 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.Name of QDN Member nominating me isMy title (Mr, Mrs, Miss)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 *My disability is:Intellectual disabilityNeurological disabilityPhysical disabilityLearning disabilitySensory disabilityOther disabilityDescription of disability:I identify as:AboriginalTorres Strait IslanderLGBTIQ+ (Lesbian, Gay, Bisexual, Transgender, Intersexual, Queer+)Coming from another cultural backgroundMy areas of interest:NDISEducationRural and RemoteHealthMedical aids and equipmentAccessibilityAgeingWomenIncome support/pensionsHousing and accommodationAssistive technologyJustice and legal issues for people with disabilityAboriginal/Torres Strait IslanderResearchEmploymentTransportHuman RightsCost of livingCulturally and linguistically diverseOtherI prefer to receive information by:EmailSocial mediaPostI would like to be involved with QDN by connecting with peers:Face to face meetingsOnline groups (regular online chats)I would like to have a voice in disability policy via:Policy discussion forum group (online or face to face meetings)Focus groups discussions (one off meetings)Consent for collection, use and disclosure of personal informationBy 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.NameSubmit
