Dying With Dignity ACT

Membership and Donation

Complete the form below to join, renew &/or donate.

    1. About You


    Your First Name

    Your Last Name

    Enter the first name & last name of your partner/spouse

    Your Email

    Street/PO Box





    2. Type of membership

    Type of Membership

    Are you

    Renewing your membershipA New memberMaking a donation

    3. Payment Method

    Select your payment method

    Direct Bank TransferCheque
    Date of Bank Transfer

    Bank Details:
    The email acknowledging your lodgment of this form will contain details of our bank account

    Cheques to:
    PO Box 55
    Waramanga ACT 2611

    4. Lodge your completed form

    Need a paper based form?

    Click here to download a paper form.

    Click here to make a Bequest