Membership form

Please print out this form and post the completed form, with your cheque, to:
QPPD, P O Box 470, Paddington Qld 4064

Title
first name/ last name
Mailing Address
City Name
State/ Postcode
Phone Home/ Work
Phone mobile/ fax
email
Comments
Electorates: Federal/ State Local shire Council/ DSQ region EQ School District

Full membership? if so, year of birth of child Associate membership?
non English speaking background? language spoken at home?
I am interested in: Children being included in regular schools Community based personal and lifestyle supports Attending learning events other (please specify)
Membership fees I enclose my membership fee of $20.00 I request a waiver of the annual fee I enclose the following as a donation