Membership Form

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There are three types of memberships: individual, family, and organsiations.

Please provide at least two ways for us to contact you.

Include a submember in your membership registration

Individual (Full)

Individual (Associate)

Family (Full)

Family (Associate)

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Privacy statement

By submitting this membership form, you consent to the collection, use, and storage of your personal information in accordance with Disabled Persons Assembly (DPA) privacy statement at www.dpa.org.nz

Code of Conduct

As a member of Disabled Persons Assembly (DPA), respectful will be evident in all interactions associated with DPA. Business related to DPA will follow the DPA constitution, strategic plan and national policy issues, which are available at www.dpa.org.nz.

First Name *

Middle Name

Last Name *

Phone 1

Address Line 1

Address Line 2

Address Line 3

Town or city *

Region *

Postal Code

Country *

Organisation memberships

Company Name

Contact preferences *

Submit as a company

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Include a submember

{{subMemberDisplayName}} {{index+1}}: {{getSubMemberName(index)}}

Choose Existing Contact(s)

Membership Level *

I would like to automatically renew my membership

First Name *

Last Name *

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Add {{subMemberDisplayName}}

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Membership auto-renews on {{sm.membershipAutoRenew.renewDate}} for {{formatAutoRenewAmount(sm.membershipAutoRenew.cost)}}

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Attendee	Admission	Amount
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	{{s.sessionLabel}}	{{s.amount === 'Free' ? 'Free' : s.amount ? formatAmount(s.amount) : ''}}

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Discount Code

Code:

-{{formatAmount(orderSummary.codeDiscount)}}

Order summary

Discounts -{{formatAmount(orderSummary.discountTotal)}}

Subtotal {{formType==='PRODUCT' ? formatAmount(productNetSubtotal(orderSummary)) : formatAmount(orderSummary.subtotal)}}

Discounts -{{formatAmount(orderSummary.discounts)}}

Delivery Cost {{formatAmount(orderSummary.deliveryCost || 0)}}

Tax {{formatAmount(orderSummary.tax)}}

Tax {{formatAmount(orderSummary.tax || 0)}}

Tax {{formatAmount(orderSummary.taxAmount || 0)}}

Total {{formatAmount(orderSummary.total)}}

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Pay Later

I will mail in a check or money order

Please mail your payment to:
BrainTree, 70 Langdons Road
Papanui
Christchurch

Amount:

{{formatAmount(totalAmount)}} NZD

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Disabled Persons Assembly Inc Membership Application Form

Membership level allows for a maximum of {{term.subMemberAllowed}} submembers.

		Contact Name	Membership Level
	{{item.contactName}}	{{item.membershipLevel==null?'-':item.membershipLevel}} {{item.startDate}} - {{item.endDate}}
No contacts.