Cart 0

Friends With Benefits Membership Form

CONTACT DETAILS

Name

First Name

Last Name

Date of Birth

Please note, you need to put the month first, not the day. We know, it's annoying but we can't change it :)

YYYY

Address

You can just provide your suburb and post code if you like!

Email Address

Phone Number

Let us know why you are signing up to be a Friend With Benefits (eg. you know someone with MD)

PAYMENT DETAILS

You will need to set up a recurring payment to us through your financial institution. We will send you our bank details once this form has been submitted. Please indicate below your payment frequency and start date so we can put you on our membership list and keep an eye out for your first payment.

Direct Transfer Payment Frequency

Select whether you wish to make your recurring payments weekly, fortnightly, monthly or yearly upfront. Please note your annual contribution totals $520.

Weekly payment of $10

Fortnightly payment of $20

Monthly payment of $43

Yearly upfront payment of $520

Direct Transfer Payment Date

This is the date that your recurring payment will be happening. Again, remember to put the month first, not the day.

YYYY

ACCEPTANCE - both of these documents can be found under About/Serious Stuff section of our website

I agree that I have read, understood and accept the Friends With Benefits Terms & Conditions.

I agree that I have read, understood and accept MDWA's policy privacy.

Friends With Benefits Membership Form

© 2023 NEUROMUSCULAR WA

ACKNOWLEDGEMENT OF COUNTRY