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Become a Member

“The information given on this form will be used word for word to list your program on the VYMA website. Please ensure details accurately reflect your program”
Membership Form (*Required Fields)
Name of Program:
 *
Name of Organisation:
 *
Aim of Program:
 *
Nominated Person:
 *
Position:
 *
Email Address:
*
Street Address:
 *
Suburb:
 * Postcode: *
Phone:
 *
Mobile:
Website:
Profile of Target Group:
 *
Age of Target Group:
 * (example: 10-20yo)
Number of young people:
 in program *
Number of mentors:
 in program *
Program Model:
*
If other please specify:
Program Setting:
*
If other please specify:
Location of Program:
 *

* Please tick appropriate box:

Please Note:
Annual membership is for the financial year

 Organisational Member - $100.00
(Which includes 1 representative named above)
Individual Member - $20.00
(Named above)


VYMA Account Details:
Bank Name: Bendigo Bank, Bank Branch: Trafalgar, BSB Number: 633 000, Account Number: 127 731 990

Post to:
Sarah Johnson, VYMA, PO Box 6017, Collingwood North VIC 3066

Please provide us with your preferred Username and Password

User Name :
 * (Aa-Zz 0-9) 6 digits min
Password:
 * (Aa-Zz 0-9) 6 digits min
Comments:
* I wish to become a Member of the Victorian Youth Mentoring Alliance and agree to be bound by the Rules of the Association.