Self Help Queensland

"Supporting people to find their own solutions to improve well being"

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Section 1 | (this information will be published in the SHQ online directory)

Group Details
Full Name of Self Help or Support Group: *
Acronym (if any):

Membership Fee:

Contact Details
Phone 1: *
Phone 2:
Mobile:
Freecall:
TTY:
Fax:

Address (for publication):

State:

Postcode:

Email1:

Email2:

Website:
Would you like your address to be displayed on a Google map on the directory listing? *
 Yes 
 No
Group Description:

Description:

What areas does your group service? *

Contact hours:

Services/Activities: *

Please list specific diseases, issues etc (if applicable) that your group caters for:

Search Facilities

Please list key words that will help people find your group:

Other Information:

Authorisation

Please note that you must be authorized to post this information on behalf of the group.

Your Full Name: * Date:
   I authorise Self Help Queensland to include the above information in the SHQ online Directory. *

Section 2 | Not for Public View (SHQ internal use only)

Contact information

Name(Contact person/s for group):

Position:

Organisation:

Phone:

Address:

State:

Postcode:

Section 3 | Free Newsletter Subscription (SHQ internal use only)

Newsletter

If you would like to receive our free quarterly newsletter please fll in your details below

Please choose only one of the following:

Email

Enter your email address if different from the group details above:

Email1:

Email2:

Post
Postal Address: Suburb: Postcode: State:

Group does not want to receive the SHQ newsletter

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Please enter the value of the security question above.

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