Complete, Print and Fax to (02) 6281 0995 Member Details Please complete Oganisation * Name of Individual or Accredited Representative of the Organisation Title * - Select - Prof Dr Mrs Mr Ms First Name * Surname * Postal Address * Town * State * Postcode * Tel (BH) * Fax Mobile Email * Please indicate if you would prefer future correspondence from ADCA in electronic format. Yes No Membership Information To enable us to better advocate on behalf of the AOD sector and to improve the delivery of services to members, it would be appreciated if you could provide the following information for inclusion in the ADCA database: How many staff does your organisation employ? How many volunteers does your organisation have? Core Business What would you describe as the core business of your organisation? (please select from the following) Prevention Programs AOD Specific Community Education School Based AOD Programs General promotion of health & wellbeing AOD Treatment Pharmacotherapies Detoxification Residential Rehabilitation Therapeutic Community Outpatient Counselling Other Family Support Policy Research Law Enforcement General Practice Workplace AOD Workforce Development Needle & Syringe Program Other (please specify) Does your organisation specifically target any particular population group? (please select from the following) Children and Young People Indigenous Australians Women Men Homeless People Culturally and Linguistically Diverse Communities Intravenous Drug Users Carers People in Custodial Settings Sex Workers Families People with comorbid mental health & AOD problems Other (please specify) Declaration In making this application, I/We declare my/our support for the mission of ADCA: ADCA, as a national peak body for the alcohol and other drugs sector, is committed to the principle of harm minimisation. ADCA works collaboratively with the government, non-government, business and community sectors to promote evidence-based, socially just, approaches aimed at preventing or reducing the health, economic and social harm caused by alcohol and other drugs to individuals, families, communities and the nation. Agreement to conditions of use: ADCA membership entitles our organisation to individual use only of the NDSIS electronic services. The use of NDSIS Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way. Any NDSIS material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost. Name Position Signature Sign here if you are printing this form or upload image of signature below. Signature image upload Date Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Year 2013 2014 2015 Name Position Signature (must be signed by nominated individual) Signature image upload Date Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Year 2013 2014 2015 Second nominated user of electronic journals Agreement to conditions of use: ADCA membership entitles me to individual use only of the NDSIS electronic services. The use of NDSIS Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way. Any NDSIS material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost. Agreement to conditions of use: ADCA membership entitles me to individual use only of the NDSIS electronic services. The use of NDSIS Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way. Any NDSIS material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost. Name Phone Email Signature (must be signed by nominated individual) Date Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Year 2013 2014 2015 Third nominated user of electronic journals Agreement to conditions of use: ADCA membership entitles me to individual use only of the NDSIS electronic services. The use of NDSIS Electronic Services including viewing, printing and downloading of individual articles is for the purpose of study, teaching and research. That the downloading of an entire journal issue in a systematic fashion is strictly prohibited and that information must not be used for commercial purposes or re-sold in any way. Any NDSIS material borrowed by me that is lost or returned damaged will incur a fine to pay for the repair or replacement cost. Name Phone Email Signature (must be signed by nominated individual) Date Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year Year 2013 2014 2015 Membership and Additional Member Services Costs Membership Categories Annual Subscription (Based on calendar year 1 Jan - 31 Dec) * $150 - Organisational Member (must be incorporated, non-government, with primary objectives including concern with alcohol and drug related issues $150 - Associate Organisational Member (Any other organisation) Additional Member Services (select if required) Drug Contents - $40.00 Addictions Information Monthly - $50.00 Payment Details Total Payable Payment Method A Cheque/Cheque/Money Order made payable to 'ADCA' at PO Box 269 WODEN ACT 2606 Direct Debit to ADCA: BSB: 112 908, ACC No. 0434 58100 Credit Card Please check all details are complete, print form, sign it and then fax to (02) 6281 0995. Thankyou. Privacy Policy ADCA collects personal information to allow us to obtain an accurate profile of our members, so as we can better meet their information needs and advocate on behalf of the sector. The names of organisations and individuals who are members of ADCA are published in the ADCA Annual Report and may be cited on other occasions as an example of the types of organisations/individuals ADCA represents. ADCA's Privacy Policy fully outlines the purposes for which information is collected and to whom it may be disclosed.
