Registration

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*
Prefix First Last
Applicant Two's Name
Only requiered if more than one person is applying - second parent/ partner
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 Country
Email Address*
Phone Mobile/ Home*
Phone - Mobile/ Home

Cleft Affected Persons Details
Name
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
Cleft Lip - to what degree was the lip affected?
Cleft Palate
- Was the hard palate (Alveolar Bone) affected?
Cleft Palate
Was the soft palate (tissue) affected?
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?
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.
Receive and Sell raffle tickets on behalf of Cleftpals QLD Inc.*
This could be for Easter and Christmas raffles.

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?*
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
Total Payable
*Total includes $10.00 Annual Membership Fee and the $ value of any donation amount specified.
$ 0.00
Payment Method*
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.

Membership with Cleftpals QLD Inc. is $10 per year