LANSW Membership Application Form

Membership is open to laryngectomees or persons with a similar communication disability, partners, carers, doctors, and allied health professionals.

Membership Benefits

FREE Welcome Pack - toiletry bag, vanity mirror, forceps, stoma cover, personal light, stoma wipes, emergency car window sticker, emergency seatbelt cover, emergency wristband, a pen, emergency neck breather wallet card, General Information and First Aid leaflet, ‘You Can Say That Again’ booklet.
Regular communications - updates on the activities of the association.
Invitations to LANSW events and functions.
Purchase Supplies - at cost or discounted, and free postage.
Access to Support Meetings - in Sydney, Newcastle and regional NSW.

Membership Fees

Membership is $10 per year, and then due each year on the 1st of January.

When your application is approved, we'll send you an invoice with options on how to pay.

Please Note: Membership is valid from when we receive payment.

Are you registering as an: *

Individual

Organisation or Hospital

Organisation or Hospital name (required) *

First Name *

Last Name *

Phone Number *

Email address *

Gender Identity

Gender Identity (optional)

Male
Female
Non-binary
Other
Prefer not to disclose
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Position *

Street Address

Address line 1

Address Line 2 *

Suburb (required) *

Postal code (required) *

State or Territory *

State or Territory (required)

NSW
ACT
NT
QLD
SA
VIC
WA
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About You

Which category best described you? *

Laryngectomee

Spouse / Partner

Sibling

Carer

Speech Pathologist

Doctor

Other

Supplier

How did you hear about us?

Hospital

Speech Pathologist

Internet/Google

Social Media

Friend or Family

Which category best describes your role in the organisation? *

Speech Pathologist

Doctor

Nurse Practitioner

Supplier

Other

Referral Hospital

None
Canberra
Chris O'Brien Lifehouse
Dubbo
Gosford
John Hunter
Liverpool
Prince of Wales
Royal North Shore
Royal Prince Alfred
St Georges Private
St Georges Public
St Vincents Private
St Vincents Public
Westmead
Wollongong
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Date of Laryngectomy Surgery

No email address?

If you do not have an email address, you can submit your application by post.
Click HERE to download the the postal application form.

To complete your application, click on the box beside 'I agree to the LANSW Terms and Conditions', and the box beside 'I am not a robot', then click on the 'Submit Application' button.

*I agree to the LANSW Terms and Conditions.

Please confirm you are a real person

THE LARYNGECTOMEE ASSOCIATION OF NEW SOUTH WALES INCORPORATED - REGISTERED CHARITY

PO Box 443, Woy Woy, NSW 2256. Registered Charity | ABN 48 862 877 872

Terms & Conditions