Membership

Membership Form

Click here to download the Membership Form

Alternatively fill out and submit this online form:

Name (required)

Address (required)

Phone (required)

Mobile

Emergency Contact (required)

Emergency Phone (required)

Please check the appropriate box (required).
Are you: a person with aphasiaa caregivera friend of a person with aphasia

The following questions relate to people with aphasia only:

Do you have any medical conditions, e.g. heart problems, epilepsy, hearing loss, etc or special
Yes/No
If yes, please
describe

Date(s) of your
stroke(s)

If your aphasia is not a result of a stroke, please indicate cause of the aphasia:

Please try to tell us about your aphasia:

Your ability to express yourself verbally:

Your understanding of what others are saying:

Your understanding of what you read:

Your ability to express yourself in writing:

Membership costs $15 annually for an individual, or $20 for (2) people from the
same family.
Payment options:
Online banking: 060 383 0179748 00 or Post to PO Box 736 Orewa

Membership Renewal Form

Click here to download the Membership Renewal Form