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.
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Disability Reference Group Member Nomination Form

All fields are required except where indicated

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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9 Coleville Crescent,
Spearwood 6163

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

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