Library Membership Form

Title (Mr, Mrs etc)
Surname(compulsory)
First name(compulsory)
Date of birth (eg. 11 Nov 1923)(compulsory)
Address(compulsory)
Suburb(compulsory)
State(compulsory)
Postcode(compulsory)
Home telephone number (include area code)(compulsory)
Business/Mobile telephone number
Email address
Department of Veterans Affairs Pension number (if applicable)
Are you of Aboriginal or Torres Strait Islander descent? (compulsory) Select an optionYesNo

We require the following details to ensure that we have current records if we are unable to contact you.

Name of alternate contact(compulsory)
Telephone number (include area code)(compulsory)

Do you have a vision impairment? (compulsory) Select an optionYesNo
Do you have a print or perceptual disability?(compulsory) Select an optionYesNo
Do you require audio books in languages other than English? If so, please indicate language.
Do you require an interpreter? If yes, please indicate language.

(Please note you may only select one type of DAISY player)

DAISY Audio books
DAISY CD player
DAISY Download player
Braille material
DAISY Audio magazines
Talking Newspapers

All library materials are subject to copyright. No unauthorised reproduction, publication, communication, adaption or distribution of these materials is permitted.

Signature of Applicant (note verbal consent here by typing name) (compulsory)

From time to time, at the request of Local Government or State/Federal Government agencies, Vision Australia Library and Information Services convert a range of printed Government information into alternative formats and distribute this information on behalf of the Government agencies.

Do you want to receive Government information in alternate formats? Select an optionYesNo

If you are under 16 years of age, Vision Australa Information Library Service requires the consent of your parent / legal guardian.

Name of parent / legal guardian
Relationship to applicant
Telephone number of parent / legal guardian (include area code)

The Vision Australia Library Information Service requires a referral from one of the following people:

Ophthalmologist; optician; orthoptist; general medical practitioner; orientation and mobility instructor; public library staff; social worker; welfare officer; special education teacher; speech pathologist; nurse; psychologist; neurologist, diversional therapist; orthopedic surgeon; physiotherapist; occupational therapist, Vision Australia staff member, nursing home staff member.

The referee may be contacted to certify that the person applying for membership meets the eligibility criteria.

Title
Surname(compulsory)
First name (compulsory)
Business/Mobile telephone number(compulsory)
Fax number
Email
Occupation / Authority(compulsory)
Organisation / Affiliation (compulsory)

Please click the "Submit" button below to successfully complete this online form.