D.A.T.A. Membership Application

Membership of the Dialysis & Transplant Association of Victoria Inc. is open to any person who is involved with renal conditions, including family, carers and friends. Membership costs only $15 per person, and is due on the first of July each year.

To apply and renew by mail

If you would prefer to apply for a new membership and send it by mail, please print out and complete the New Members Form

Or to renew you membership, just print out and complete Renewal Form

When you complete either form, please send it with your remittance to:

The Treasurer
D.A.T.A. Inc.
P.O. Box 159
Forest Hill VIC 3131

Membership for Individuals

Membership for Associates

To apply for a Membership as an individual, please complete the form below:

Member Details
Prefix
- Mr
- Ms
- Mrs
- Prof
- Dr
First Name*
Last Name*
E-mail*
Email Notifications
- Yes
- No
My Preferred Contact Telephone
- Home Phone
- Business or Work Phone
- Mobile Phone
Telephone (Home) Required phone number format: ## #### ####
Telephone (Business) Required phone number format: ## #### ####
Mobile Required phone number format: #### ### ###
Your age group
- Under 18
- 18 to 24
- 25 to 34
- 35 to 44
- 45 to 54
- 55 to 64
- 65 to 74
- 75 plus
Your Work
Where do you work?
Job Title
Account Password
Password* Type your password. Minimum length of 8 characters.
The password must have a minimum strength of WeakStrength indicator
Repeat Password* Type your password again.
- Payment Details & Billing Address
- First Name*
- Last Name*
- Address*
- Town / City*
- State / County*
- Postcode / Zip*
I require a receipt*
- Yes
- No
Shoestring Newsletter Delivery
- Post
- Email
Would you like raffle tickets to help us fundraise?
- Yes
- No
Renal Condition
Do you have a carer?
- Yes
- No
Carer’s Full Name (If applicable)
Carer's Relationship to Member
- Wife
- Husband
- Partner
- Mother
- Father
- Other
Other
Type of treatment
- End Stage Renal Failure ESRF
- Haemodialysis
- Peritoneal Dialysis
- Transplant Patient
- Donor
- Other
Other Please provide details
Hospital
Dialysis Unit (If different to Hospital)
reCAPTCHA*

Send these credentials via email.

About DATA

We are a patient self-help group made up of people with kidney failure and their families, carers and friends. We support them by the provision of holiday homes at Rosebud and Yarrawonga.

Rules of the Dialysis & Transplant Association
of Victoria Inc. Click Here

Contact us

The Dialysis and Transplant Association
of Victoria Incorporated (D.A.T.A)

P.O. Box 159, Forest Hill,
Victoria 3131
Telephone: (03) 9894 0377
Email us: Click here

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Useful links

Membership Application Form
Rosebud Holiday Home
Yarrawonga Holiday Home
Social Welfare Grants
ShoeString Newsletters

Association Rules
Privacy Policy
Terms and Conditions
Site map

About
Benefits and Services
ShoeString Newsletter
Contact
Members
- Login
- Become a Member

To apply and renew by mail

Member Details

Your Work

Account Password

Payment Details & Billing Address

Renal Condition