Port Macquarie Community Gardens Inc. Membership Form
Thank-you for your interest in the Port Macquarie Community Gardens! We trust that you will find your
association with the Port Macquarie Community Garden to be a rewarding experience. Please fill in this
form and submit it, after reading our Mission Statement below (also available at www.thelostplot.org.au).
First Name: Click here to enter text.
Surname: Click here to enter text.
Organisation: Click here to enter text.
Street Address: Click here to enter text.
Town/Suburb: Click here to enter text.
Postcode: Click here to enter text.
Phone (Home): Click here to enter text.
Phone (Work): Click here
Mobile: Click here to enter text.
Email: Click here to enter text.
PLEASE NOTE: Email is our primary form of communication
Date of Birth: Click here to enter DOB DD/MM/YYYY. (optional)
EMERGENCY:
Emergency Contact Person: Click here to enter text.
Relationship: Enter text.
Phone (Home): text.
Phone (Mobile): Enter text
Phone (Work):Enter text.
What skills, knowledge or experience could you contribute?
Click here to enter text.
What activities would you like to be involved in?
Management committee
Gardening
Nursery
Compost/worm farm
Educational activities
Administration
Promotion / publicity / media
Stalls / displays at events
Organising events
Research
Arts projects
Other Click here to enter text.
ck all that apply)
Are there any special requirements that you need to support your participation?
Click here to enter text.
Port Macquarie Community Gardens Inc. - Membership Form
Last Reviewed: Jan 2015
Page 1 of 2
PORT MACQUARIE COMMUNITY GARDENS MISSION STATEMENT
Port Macquarie Community Gardens aims to establish and support community gardens.
They will be places which encourage opportunities for:
 ________________________ Sharing knowledge and skills;
 ________________________ Building and strengthening community connections;
 ________________________ Sustainable gardening with a focus on food;
 ________________________ Health and education;
 ________________________ Growth and reflection; and
 ________________________ Celebration, arts and creativity.
They will be governed by the core values of diversity, inclusiveness, sharing, respect and participation.
MEMBERSHIP TYPE:
Membership aligns with the financial year. If you join between July 1 st and Dec 31st, full fee as above will
apply. If joining between Jan 1st and June 30th, half of the annual fee will be charged.
Single ($20)
Family ($30)
Concession (Health Care Card, Student Card or Pension Card) ($10)
Organisation ($100)
Donation (if interested, please indicate how much you can donate) enter amount here
I give permission for photographs or videos taken of me during my participation to be used for
promotional purposes as required (if this box is not ticked, it remains your responsibility to ensure you
are not in any photographs or videos taken at the Lost Plot).
PAYMENT OPTIONS: your membership will not be valid until payment is received
Bank Transfer (preferred)
A/C Name: Port Macquarie Community Gardens Inc
BSB: 650 000
A/C #: 516 625 001
Email copy of form to: [email protected]
Cheque
Payable to: Port Macquarie Community Gardens Inc
Post payment and form to: PO Box 5702
Port Macquarie BC NSW 2444
CONDITIONS OF MEMBERSHIP:
□ I understand that medical conditions, allergies, disabilities or past injuries may affect my participation
and that it is my responsibility to ensure that I am fit for the activities I undertake in the garden.
□ I will participate in a way that reflects the principles and values of Port Macquarie Community Gardens
Inc. (as outlined at www.thelostplot.org.au). All policies and procedures are available on the website.
□ I understand that it is a requirement for the PMCG Inc. to record my name and address (as provided
above) in a register of members. This may be made available to other members on request under s27
of the Association Incorporation Act.
□ I agree to pay the appropriate membership fee.
SIGNATURE:
DATE:
Click here to enter your electronic signature
Click here to enter date DD/MM/YYYY
Port Macquarie Community Gardens Inc. - Membership Form
Last Reviewed: Jan 2015
Page 2 of 2