Cockburn Seniors Centre Membership Form

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Cockburn seniors centre membership form

All fields are required except where indicated
 

Please enter the name you would like written on your badge to wear at the centre
Note: 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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Contact

Address

9 Coleville Crescent,
Spearwood 6163

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

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