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Membership

Join Online

To become a member of Diabetes WA and access the growing range of associated benefits, you can join online by using the form below. The form is an easy 4 step process for which and you will need your credit card details to complete the process. Payment processing is not immediate, your membership application will be addressed within 48 hours.

Step 1 of 4: Membership Details

To begin the Join Online process please enter your personal details below. When you are happy with the information click the 'Next' button.

Fields marked with (*) are required fields.


Personal Details

Title:*
Mr   Mrs   Ms   Miss   Other 
Surname:*
Given names:*
Date of birth:*
DD   MM   YYYY


Postal Details

Address:*
Suburb:*
Postcode:*


Contact Details

Daytime telephone:*
Mobile:
Email:*
 


Diagnosis Details

Do you have diabetes?

Type 1
Type 2
Gestational
or

Are you at risk of Type 2 diabetes?

Impaired Glucose Tolerance (IGT)/Impaired Fasting Glucose (IFG)
Have one or more risk factors


Membership Referral

I heard about Diabetes WA membership from:*

Looking around the website
My GP
My NDSS starter pack
My Sub-Agent
DIAL - Diabetes Information & Advice Line
Diabetes WA e-Blast
Diabetes WA course or program (eg Speak Out, Cook Smart, Shop Smart, Living with Diabetes)
Diabetes WA Educator or Dietitian consultation
Diabetes WA Fundraising appeal
Diabetes WA Member Benefit Partner
Other - please type:
 


Membership Details

Membership Type:*
(Concession membership is available to Seniors, Pensioners, DVA, Healthcare or Student cardholders, or a person under 18 years of age)


Full Member (1 Year) $50.00
Full Member (2 Years) $90.00
Concession Member (1 Year) $26.00
Concession Member (2 Years) $46.00