Cockburn Seniors Centre Membership Form

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Cockburn Seniors Centre Membership Form

Please note this form is for City of Cockburn residents only.

All fields are required except where indicated.

Please enter the name you would like written on your badge to wear at the centre
Note: You must be a City of Cockburn resident. Street number and street name are needed for all addresses.
I am an Aboriginal/Torres Strait Islander:
I am from a Non-English speaking background:
I speak another language other than English at home:
I would like to receive our program and newsletter by email:
Our program and newsletter contain information on the City's range of activities, classes, events, outings and courses. You can also get a hard copy of the program and timetable at the centre or online
Please specify any dietary requirements e.g. if you are a celiac, diabetic, vegetarian
Please specify any medical conditions that we should know about
I would you like to be assessed for the Senior Centre transport service:
We may be able to provide transport to the centre for people who do not have transport.
E.g. partner, friend, son, daughter
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9 Coleville Crescent,
Spearwood 6163

Po Box 1215, Bibra Lake DC,
Western Australia, 6965

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