ME/CFS Australia (SA) Inc
PO Box 28, Hindmarsh,
South Australia 5007


Full Name:

( Mr / Mrs / Ms / Miss / Dr ) _____________________________________________________

Postal Address: ___________________________________________________________________

Suburb: ________________________________________   Postcode: ______________________

Phone: (H) _________________    (W) _________________
    (M) ______________________
Email: ___________________________
Date of Birth: ______ / ______ / ______

Which Best Describes You?
I suffer from:
Check box ME/CFS            Check box FM            Check box MCS            Check box Other ____________________________________

Or, I am a:
Check box Carer             Check box Relative             Check box Friend             Check box Health Professional / Scientist
Annual Subscription Rates – What Can You Afford?
(Rates are due on 1 July each year)

We think everyone affected by ME/CFS should be able to join our society – and not be prevented due to cost. So, please donate what you can afford, even if it's only $5*. It costs the society about $80 per year, per member, to operate. We used to ask $38 for an adult and $25 for concession. If you can donate more to help subsidise those less well off, we would all really appreciate it.
For my membership I wish to contribute: $ _________________
(*$5 of your contribution will be your official membership fee [GST inc.],
while additional contributions will be classified as donations. Donations
of $2 or more are tax deductable and receipts will be posted if required.)
Payable to "ME/CFS Australia (SA) Inc."

Send to: ME/CFS Society,
         GPO Box 28,
         Hindmarsh SA 5007
(please don't send cash in the mail)
Credit Card Payment
Name on Card: ___________________________________
VISA / MasterCard / Bankcard   EXP _____ / _____
Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box  Check boxCheck boxCheck boxCheck box
Signature: ____________________________________

I agree to uphold and abide by the constitution of the ME/CFS Australia (SA) Inc. The constitution can be found on our website at

Signed: _________________________________________   Dated: ______ / ______ / ______

Check box I would like to receive society notices (email bulletins with ME/CFS news, updates and reminders, etc) via email.
Check box I would like to receive society notices (seminar reminders and special notice of media events, etc) via SMS.
Check box I (or a friend or relative) would like to volunteer some time, service or business sponsorship to assist the society.
Office Use Only

Date received: ______ / ______ / ______     Membership No:  _______________________
Entered in database:   ________________     Receipt No:     _______________________
Membership pack sent:  ________________     Volunteer name: _______________________