Please enable JavaScript in your browser to complete this form.Type of membershipQDN 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.Name of QDN Member nominating me is *My 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 *If you are not a Queensland resident, please tell us your connection to Queensland? *I identify as: *AboriginalTorres Strait IslanderLGBTIQ+ (Lesbian, Gay, Bisexual, Transgender, Intersexual, Queer+)Coming from another cultural backgroundOtherIf Other, please describe:Pronouns:I would prefer to receive information by: *EmailTextI would like to be involved with QDN by connecting: *Face to Face meetingsOnline groupsI would like to have a voice in disability policy via: *Policy discussionsFocus groupsMy Disability Is: *Intellectual disabilityNeurological disabilityPhysical disabilityLearning disabilitySensory disabilityOther disabilityPlease describe your disability: *My areas of interest - Please tick the box/ boxes that you are interested in.Aboriginal and Torres Strait IslanderAccessibilityAgeingAssistive technologyCulturally and Linguistically diverseCost of livingDigital InclusionDisaster recoveryEducationEmploymentEnvironmentHealthHuman rightsHousing and AccommodationIncome Support/PensionsJustice and Legal IssuesLGBTIQ+Medical Aids and EquipmentMen's IssuesNDISRural & RemoteTransportWomen's IssuesOtherIf Other, please describe: Consent for collection, use and disclosure of personal membership application form 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
