Q Shelter Membership Form

Membership Number

Reference Number

Please indicate which is relevant to this application?*

Membership renewal
New membership application

Type of Membership*

Membership Fees for Current Financial Year

Annual Total Fee

$ 0.00

Paid By Invoice

Please tick this box if you like to pay by invoice

Three years membership and you get 15% off

Save 15% on your Membership Fees by upgrading to a three-year Membership

Save 15% on your Membership Fees by upgrading to a three-year Membership (Invoice)

Save 15% on your Membership Fees by upgrading to a three-year Membership

Three Years Subscription

Price: $ 0.00

Member organisations providing housing, homelessness, or community services are eligible for inclusion in Q Shelter’s Employee Assistance Program. The EAP features a base charge $100 per annum for up to five employees, with a $20 surcharge for each additional employee.

You can find more information about the EAP and what this product includes here.

All participating organisations will be asked to sign an agreement stating the terms, inclusions and responsibilities. Responsibilities include informing Q Shelter about changes to staffing numbers so that coverage under the EAP is maintained.

Add EAP (Employee Assistance Program) to your Membership

Add EAP (Employee Assistance Program) to your Membership

EAP

Price: $ 100.00

ABN

Number of Employees

Please enter a number from 1 to 50.

Additional Employee (Over 5 Employees, $20 per employee)

Price: $ 30.00

Would you like to be contacted by a Q Shelter employee to understand more about EAP membership and what is on offer?

Would you like to be contacted by a Q Shelter employee to understand more about EAP membership and what is on offer?

Your membership will automatically roll over each year resulting in a charge to your credit card. If you do not want this to happen, please tick this box.

Your membership will automatically roll over each year resulting in a charge to your credit card. If you do not want this to happen, please tick this box.

Name*

Name (This must be the nominated representative if applying as an organisation)*

Organisation*

Position / Role

Landline*

Mobile Number*

Confirm Mobile Number*

Email*

Confirm Email Address*

Address*

Postal Address (If different from above)

Additional Contacts

Please list additional contacts that we can get in touch with regarding your Membership

Name	Email

Credit Card

Q Shelter uses Stripe as their payment gateway. Stripe has been audited by a PCI-certified auditor and is certified to PCI Service Provider Level 1. This is the most stringent level of certification available in the payments industry.

Signature*

*

By signing this declaration, I certify that all information is true and correct to the best of my knowledge. I acknowledge my application is subject to approval by the Q Shelter Management Committee. I understand that my application for membership can be rejected based on certain provisions in the Q Shelter Constitution. I agree to abide by all rules outlined in the Q Shelter Constitution which is available on the Q Shelter website.

Q Shelter Members receive direct notification of events, news, information, products and services including regular updates about the Deck Resource Hub for Housing and Homelessness Services. Please check this box if you would prefer not to be sent this information.

*

I have reviewed the EAP terms and conditions.

So we understand more about your needs and interests, is your organisation or interest predominantly as:

What services and products from Q Shelter are most important to you? You can tick more than one:

Training
Other events
Resources and tools
Consultancy services
EAP
Advocacy on key issues
Regional networks
Discounts on events and services
Other

What service or product is that?*

Q Shelter is working to improve member services. Please tell us how we can improve member services in ways that will assist you?

Application Date (existed members)

Type of Membership (existed members)

Organisation (existed members)

Title (existed members)

First Name (existed members)

Last Name (existed members)

Membership Form

Membership Register Form Test