Disability Reference Group Membership Form

Please note: Submitting an expression of interest does not guarantee membership. The City of Cockburn Disability Access & Inclusion Officer with be in contact regarding your application.
Print Form

Disability Reference Group Member Nomination Form

All fields are required except where indicated
Note: street number and street name are needed for all addresses
Group Members (please select any which apply):

Do you give permission for digital photos to be taken of yourself by the City of Cockburn or any of its authorised agents during your membership to the Disability Reference Group:
Photos taken may be used by the City for any internal and external purposes i.e. newspapers, posters, printed newsletters, billboards and online media.

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City of Cockburn
Whadjuk Boodja
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)

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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 and present.