FORMS Spinal Support NZ Membership Form 1. PERSONAL DETAILSI would like to * Required Become a new member Update my details Although filling in your address and phone number may not be required for some options, we encourage you to complete these details. Your local Coordinator can then inform you about any social events or Gatherings organised in your area.Full Name * Required First Middle Last Date of Birth * Required DD slash MM slash YYYY Home Address * RequiredHow did you have your accident/impairment?Level of InjuryWork Type (e.g. Employed)Preinjury WorkFunder: ACC/MOH?Would you like a Peer Support? Yes No 2. CONTACT DETAILSMobileHomeWorkEmail * Required 3. MEDICAL DETAILSIs your injury due to an accident? * Required Yes No Level of Injury: * RequiredComplete / IncompleteDate of Accident: * Required DD dash MM dash YYYY Please briefly describe how the accident occurred: * RequiredIs your injury due to medical reasons? Yes No Level of Injury: * RequiredComplete / IncompleteDate of Condition: * Required DD dash MM dash YYYY Please briefly describe medical condition: * Required4. OTHER (Optional)Nationality:Citizenship:Religion:Do you smoke? Yes No Do you drink? Yes No Occupation(s):Hobbies / Interests:Describe your Personality: (check which ones you feel apply to you) Friendly Outgoing Easygoing Shy Reserved Positive Other (please specify) Please specify your PersonalityDescribe your attitude towards life: (check which ones you feel apply to you) Conservative Middle of the Road Broadminded Other (please specify) Please specify your attitude towards life5. BUDDY Would you like a Buddy? * Required Yes No Is gender important? * Required Yes No Is age important? * Required Yes No ACC/MOH issues relevant? * Required Yes No Is nationality important? * Required Yes No Religion? * Required Yes No Further CommentsI would like to receive a copy of the information I have submitted Yes No Δ The Supporter Newsletter Form Note: More questions will appear as you fill in the form. 1. I would like to Receive the Newsletter Update my details 2. I would like to Receive a paper copy of The Supporter Newsletter Receive The Supporter Newsletter by email Receive The Supporter Newsletter by email and stop receiving my paper copy 3. I would like to I would like to update my address Receive the newsletter by email and stop my paper copy Although filling in your address and phone number may not be required for some options, we encourage you to complete these details. Your local Coordinator can then inform you about any social events or Gatherings organised in your area.Name for Email List * Required First Last Email Address for Email List * Required Enter Email Confirm Email Contact Email for receiving papercopy * Required Enter Email Confirm Email Name For Posting the Newsletter * Required First Last Phone Number (with area code please) * RequiredAddressAddress * RequiredPlease stop the paper copy being sent to my address at:Name on the current papercopy First Last Please stop the paper copy being sent to my address at:Email for contacting regarding changing postal address * Required Enter Email Confirm Email My previous postal addressMy new postal addressMy Phone Number (with area code please) * RequiredFurther commentsI would like to receive a copy of the information I have submitted Yes No Δ Spread the love
