Type of application
Title (e.g. Mr/Ms) *
First Name *
Surname *
Street Address *
Suburb/Town *
Postcode *
Email Address *
Date of Birth *
Phone Numbers, please specify at least one.
Home Phone
Work Phone
Mobile
Fax
Please fill this section in if you are applying for new membership.
Details of Crime
PVOH DoB
PVOH DoD
Primary Victims’ Name
Relationship to you:
Date of crime:
Place of Crime:
Please tell us anything else you would like us to be aware of about your experience of serious personal violence:
Other Information
I would like to have my first name and phone number placed on a list shared with other members Yes No *
I would like to learn more about supporting others through your peer support program Yes No *
I would like to have my loved one included on angelhands Remembrance list. Yes No *
I will provide angelhands with a photo and the wording Yes *
CONFIDENTIALITY
In the event of my admission as a member, I agree to be bound by the rules of the Association for the time being in force. I understand in order to maintain our members' privacy, I will not give out telephone numbers and/or addresses of fellow members or speak to the media, non-members or any organisation, about private conversations without the express permission from the member concerned and/or our Director. Any breach of confidentiality may lead to expulsion from the group. *
Enter the letters as they appear in the box
Thank you, the form has been submitted. You will be contacted shortly.
We may require you to print and sign a declaration form.
If you don't hear from us within a week please email admin@angelhands.org.au.
acebook