Membership/Renewal Form

Please use this form to apply for membership of the
Bayside Climate Change Action Group (BCCAG).

Also use the form for renewing your Membership.

Direct questions to Ken Blackman on (03) 9521 6184.

Those who prefer a printed form can use this PDF, which can
be completed hand, then posted to the address on the form.

1 - APPLICANT
First Name 
ERROR - Please enter your First Name.
Last Name 
ERROR - Please enter your Last Name.
Address 
ERROR - Please enter a valid street address.
Suburb 
ERROR - Please enter the name of your Suburb.
Postcode 
ERROR - Please enter your Postcode.
Phone (Home)
ERROR - Please enter your Home Phone Number.
Phone (Work)
ERROR - Please enter your Work Phone Number.
Phone (Mobile)
ERROR - Please enter your Mobile Phone Number.
Email Address 
ERROR - Please enter a valid Email Address.

2 - DECLARATION

I am the applicant whose details appear above. I declare that I support the following BCCAG Ojectives and hereby apply to become/continue as a member of BCCAG:

  1. Highlighting to government and others the level of community concern about Climate Change and related policies;

  2. Working with businesses and local council to reduce greenhouse emissions and to provide residents with sustainable energy solutions;

  3. Working with residents to reduce Climate Change impacts; and

  4. Working with community groups to provide education about Climate Change impacts and responses.

ERROR - Please confirm that you support the BCCAG Objectives.

3 - DONATION

Membership of BCCAG is free. The organisation is able to carry out its objectives by virtue of donations. Any donation you are able to make to the Trust Fund would be most welcome.

I will donate: 
Invalid Input
If Other Amount 

I will pay by


Invalid Input

4 - INTERESTS

I would like to learn more about the following BCCAG projects (see list of projects in the 2010 Action Plan), and/or contribute actively to BCCAG as follows:
Invalid Input

5 - APPLICATION

You are now ready to submit your application. Please press the SEND button.