QDN Supporter Application

• QDN supporter – free to join

* By this application you are applying to be a supporter of QDN and agree to be bound by its constitution.
**QDN is covered for $20 000 000 in Public Liability insurance.
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 create a free one through Google. Find out more here: https://support.google.com/mail/answer/56256?hl=en. You can copy and paste the link into your browser.)

My best phone number *

My address (street number and name or PO Box) *
Suburb *
Postcode *

I identify as: *

• Aboriginal
• Torres Strait Islander
• LGBTIQ+ (Lesbian, Gay, Bisexual, Transgender, Intersexual, Queer+)
• Coming from another cultural background
  
• None of the above

My areas of interest: *

• NDIS
• Education
• Rural and Remote
• Health
• Medical aids and equipment
• Accessibility
• Ageing
• Women
• Income support/pensions
• Housing and accommodation
• Assistive technology
• Justice and legal issues for people with disability
• Aboriginal/Torres Strait Islander
• Research
• Employment
• Transport
• Human Rights
• Cost of living
• Culturally and linguistically diverse
• Other

I’d like to receive information by: *

• Emails
• Social Media
• Bulk Emails
• Phone Calls
• Mails

I would like to be involved with QDN by connecting with peers: *

• Face to face meetings
• Online 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 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.

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