Cockburn Seniors Centre New Members - Membership Form

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Cockburn Seniors Centre New Members - 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.

Emergency Contact Details

E.g. partner, friend, son, daughter
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9 Coleville Crescent,
Spearwood 6163

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

Office opening hours:
8.30am to 4.30pm
Monday to Friday (excluding public holidays)

Language Support

Cockburn Nyungar moort Beeliar boodja-k kaadadjiny. Koora, yeyi, benang baalap nidja boodja-k kaaradjiny.
Ngalak kaadatj dayin boodja, kep wer malayin. Ngalak kaadatj koora koora wer yeyi ngalang birdiya.

City of Cockburn acknowledges the Nyungar people of Beeliar boodja. Long ago, now and in the future they care for country.
We acknowledge a continuing connection to land, waters and culture and pay our respects to the Elders, past, present and emerging.