Become a Rebound WA Member To start the membership process, please fill out this form. Membership* This is my first time signing up for a Rebound WA membership. Please let us know if this is your first time applying for Rebound WA membership.Name and Contact InformationPlease provide your name and contact information.Title*Ms.Mr.Ms.Mrs.Dr.Name First Last Address Street Address Address Line 2 Suburb State Postcode Phone - Home*Phone- Mobile*Email* Member DetailsWho is filling this membership form out?* I am a person with a disability and am requesting membership for myself. I am filling this form out for a child/individual with a disability. If you are filling this form out for an individual/child with a disability, what is your relationship?Member information*NameDate of BirthDisability/Able BodiedWould you like to volunteer? (Yes/No)Gender YesNoYesNoMaleFemaleNon-BinaryOther Please fill out this information: - If you are an individual with the disability signing yourself up. - If you are a parent/guardian, please fill a row for yourself and a row for the child with a disability.What are your pronouns?*Ex. She/Her; They/Them etc.Disability InformationInformation about your disability informs the the sport and recreational opportunities that are available.Member disabilities* Paraplegia Quadriplegia Cerebral Palsy Stroke Amputee Other If you marked "other" or have additional disabilities you'd like to share:How did you hear about Rebound WA? [Please Specificy]* Hospital Advertising/Media Referral from a service provider Word-of-Mouth Do you have additional medical concerns?Please share any additional medical conditions/history that may affect your participation in sport and recreation, such as asthma, allergies, etc. Sport DetailsThis information helps us suggest sport and recreation programs that you may be most interested in. Sport specific classifications (if known):Main sport(s) of interest* Athletics Archery Para Badminton Bowls Paracycling Paracanoeing Paratriathlon Powerlifting Wheelchair Basketball Wheelchair Rugby Sailing Shooting Other What are your recreation interests?Is there anything else you'd like to share about your sporting and recreation interests:Emergency Contact InformationName* First Last Relationship to member?*Mobile Number*Is there any additional information you'd like to share with Rebound WA?NameThis field is for validation purposes and should be left unchanged.
