Cockburn Seniors Centre New Members - Membership Form

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Seniors Centre Membership Form

Please note this form is for City of Cockburn residents only (proof of residency must be shown)

All fields are required except where indicated.
 

Please enter the preferred name you would like written on your membership card
Note: You must be a City of Cockburn resident and proof of residency is required to be shown when paying for membership. Street number and street name are needed for all addresses.
I am an Aboriginal/Torres Strait Islander:
I am from a Non-English speaking background:
I speak another language other than English at home:
I would like to receive our program and newsletter by email:
Our program and newsletter contain information on the City's range of activities, classes, events, outings and courses. You can also get a hard copy of the program and timetable at the centre or online
Please specify any medical conditions that we should know about
I would like to be assessed for the Seniors Centre transport service:
We may be able to provide transport to and from the Centre for people who are transport disadvantaged. This is an assessed service.

Emergency Contact Details (optional)

E.g. partner, friend, son, daughter
Declaration:

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Contact

Address

City of Cockburn
Whadjuk Boodja
9 Coleville Crescent,
Spearwood 6163

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

Office opening hours:
8.30am to 4.30pm
Monday to Friday (excluding public holidays)

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Cockburn Nyungar moort Beeliar boodja-k kaadadjiny. Koora, yeyi, benang baalap nidja boodja-k kaaradjiny.
Ngalak kaditj boodjar kep wer kaadidjiny kalyakool yoodaniny, wer koora wer yeyi ngalak Birdiya koota-djinanginy.

City of Cockburn acknowledges the Nyungar people of Beeliar boodja. Long ago, now and in the future they care for Country.
We acknowledge a continuing connection to land, waters and culture and pay our respects to the Elders, past and present.