Membership

By joining CleftPals QLD Inc as a paid financial member, you are helping to cover our operational costs such as insurances, phone line and storage fees for our stock. It’s a great way to help us to continue to operate and to be able to provide continued support to families.

Cleftpals QLD Inc. Membership Application Form

Membership Application Form

Step 1 of 7 - Application Type

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• Membership with Cleftpals QLD Inc. is $10 per year

• Application Type

  All fields marked with * are mandatory
• This application is for:*
  New MembershipRenewal of Membership
• I/ We are applying for membership to Cleftpals Qld Inc. as -*
  Parent/sCleft Affected AdultHealth ProfessionalOther
• Other - Please specify

• Applicant/s Details

  All fields marked with * are mandatory. Cleftpals QLD Inc. adhere to a strict code of conduct regarding privacy and information. Your details and information will not be shared with any outside or third parties without first seeking your permission.
• Applicant One's Name*
  Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last
• Applicant Two's Name
  Only requiered if more than one person is applying - second parent/ partner
  Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last
• Residential Address*
  Street Address City State / Province / Region ZIP / Postal Code
• Postal Address*
  Same as previous
  Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Email Address*
• Phone Mobile/ Home*
• Phone - Mobile/ Home

• Cleft Affected Persons Details

• Name
  Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last
• Child's Date of Birth/ Estimated Due Date
  Day

  Month

  Year
• Birth/ Delivery Hospital
• Birth Town/ City (Please include Country if outside of Australia)
• Cleft Condition*
  Please select the cleft affected areas
  • Lip
  • Palate
• Cleft Lip
  Which side of the lip was affected
  Unilateral - Left Side OnlyUnilateral - Right Side onlyBilateral - Both sides
• Cleft Lip - to what degree was the lip affected?
  Complete - cleft continues into the noseIncomplete/ Partial - formed in the top of the lip as either a small gap or an indentation in the lipBilateral mixed - Complete one side, incomplete the other
• Cleft Palate
  - Was the hard palate (Alveolar Bone) affected?
  NoUnilateral - Left side onlyUnilateral - Right side onlyBilateral - Both left and right sides
• Cleft Palate
  Was the soft palate (tissue) affected?
  NoUnilateral - Left side onlyUnilateral - Right side onlybilateral - Both left and right sidesSubmucose cleft palate
• Other cleft condition i.e Tessier Cleft, Microform Cleft
• Conditions/ Syndromes
  Has your child/ you been identified as having an other assiciated condition? i.e. Sticklers Syndrome, PRS - Pierre Robin Sequence, VCFS - Velo Cardio Facial Syndrome. - Please specify
• Is there a family history of cleft conditions?
  YesNoUnknown
• Additional Information
  Please add any additional information you feel is relevant.

• Surgery Details (If Known)

• First Surgery

• Surgery Type
  • Lip Repair
  • Soft Palate Repair
  • Hard Alveolar Palate Repair
• Surgery Date
  If unknown leave blank or put in an approximate date
• Surgeon - If Known
• Hospital

• Second Surgery

• Surgery Type
  • Lip Repair
  • Soft Palate Repair
  • Hard Alveolar Palate Repair
• Surgery Date
  If unknown leave blank or put in an approximate date
• Hospital
• Surgeon - If Known

• Third Surgery

• Surgery Type
  • Lip Repair
  • Soft Palate Repair
  • Hard Alveolar Palate Repair
• Surgery Date
  If unknown leave blank or put in an approximate date
• Hospital
• Surgeon - If Known
• Additional Information
  Please add any additional information you feel is relevant.

• Permissions

  I/ We agree to - (Please check the relevant box)
• Receive information via email?*
  This may incude updates on what we are doing, new promotions, news letters and invitations. Cleftpals QLD Inc. will never give your infomation out to third parties without first obtaining your permission.
  YesNo
• Receive and Sell raffle tickets on behalf of Cleftpals QLD Inc.*
  This could be for Easter and Christmas raffles.
  YesNo

• Gift Card Redemption

  Thanks to Kedron Wavelle Services Club, CleftPAL's QLD Inc is able to offer financial members a $40 pre paid visa gift card to be used towards hospital costs i.e. fuel, parking, food, etc. Card numbers are limited. One card per household. Applicant must be 18 years of age.
• Would you like to claim a $40 gift card to help towards hospital costs?*
  YesNo
• Date of Birth*
  We require your date of birth. This is to proove that you are 18+ years of age.
  Day

  Month

  Year

• Gift cards are issues by iChoose. Card issing list is sent to card issuer on fridays and cards can take 7-10 days to be processed and issued. If you have any issues with card activation please contact Cleftpals QLD Inc first at feeding@cleftpalsqld.org.au with where the activation issue is. This will save you a fee against your card.

• Membership Payment

• Annual Membership Fee*
  Price:
• Donation - optional
  All donations over $2.00 are tax deductable. If you require a receipt please check the box below. Please help us continue to provide support and feeding equipment to families by making a donation. These donations help cover operational costs and help keep the costs to families down.
• Donation Receipt
  No Receipt RequiredYes - Please PostYes - Please Email
• Total Payable
  *Total includes $10.00 Annual Membership Fee and the $ value of any donation amount specified.
  $ 0.00
• Payment Method*
  PayPal/Credit Card (redirects to PayPal card processing services)Direct Bank Deposit - See below for details
  Information relating to payment will automatically appear below

• Direct Bank Deposit Details

  Direct Deposit Bank Details: BSB:638-070 (Heritage) A/C No: 729 1248

• Paypal/ Credit Card processing.

  Upon submitting this application form you will be automatically directed to a payment screen.