Friends of Black Rock House Membership Form

Membership fees are $25 per household per year and $500 for lifetime membership.

Please complete the form below. Once completed please pay your membership fee as follows:

  • via EFT deposit to BSB 633000  A/c 138 371 265
  • by mailing your cheque made out to Friends of Black Rock House Inc to PO Box 200, Black Rock VIC 3193

Thank you - we look forward to welcoming you

NAME AND FAMILY DETAILS

For example Mr, Ms, Mrs, Miss, Dr
DD/MM/YYYY

PHONE AND EMAIL

ADDRESS

BECOME INVOLVED AT BLACK ROCK HOUSE

Please check all that apply to you
Please check all that apply to you

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