Membership Form

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I would like to become a “Friend of Childsafe (CAPFSA)”       (Minimum R50)
I would like to become a member of Childsafe (CAPFSA) (includes newsletter):
Regular (R100)	Bronze (R500)	Silver (R5 000)	Gold (R25 000)	Diamond (R100 000)	Disa (R250 000)
I would like a year's subscription to the Childsafe news   R30 annually
I would like to receive more information on the activities of Childsafe
I would like to become a project sponsor, please contact me
I would like to do voluntary work for Childsafe
Personal Details:
Title:  Prof/Dr/Mr/Mrs/Ms/Miss
Name:  ……………………………………………………………………………………..……………….……………….
Organisation/Institution/Company:  ……………………………………………………………………….……………
Postal address:  ………………………………………………………………………….………………….……………
Telephone: Home:  ……………………….………Work:………………….…………… Cell: ……………………… .
Fax: …………………………………….……… E-mail: ……………………………………….………………………….
Total payment enclosed: R ………………………………….…………  Date: ………………….……………………

Please fax this completed form and your proof of payment to Childsafe +27 (0)21 685 5331.

Childsafe has also devised a package for Honourable Membership, for those who wish to become Gold, Diamond or Disa Members of Childsafe.  For further information contact Childsafe.

Please make all cheques payable to The Child Accident Prevention Foundation.

KOVSSA/CAPFSA BANKING DETAILS
Account holder name: KOVSSA / CAPFSA
Type of account: Cheque
Bank: Standard Bank
Branch: Rondebosch (025-009)
Account Number: 270590897

Return this information to:
Childsafe
P.O. Box 791
Rondebosch, 7701
Or email us at capfsa@pgwc.gov.za