Individual Sponsorship Form

IDFA is seeking individual sponsorship to assist patients, carers and their families to attend the National Conference in July 2016. Please complete this form and thank you so much for your support.

Name: First Last E-mail: Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Please list your chosen Donation or Sponsorship: Donation $20 Donation $50 Sponsor a patient family fun night $80 Sponsor a patient conference dinner $99 Donation $100 Donation $150 Sponsor a patient & carer family fun night $160 Sponsor a patient & carer conference dinner $198 Donation $200 Donation $250 In return for your sponsorship, IDFA will: List your name in the conference participant handbook List your name as a conference sponsor in the IDFA Annual Report In recognition of our sponsors we would like to invite you to attend the conference dinner on Saturday 7th July 2016. Would you like to attend? Yes No Maybe Please invoice me for the sponsorship above: Yes - invoicing incurs GST and therefore is not a tax deductible item No I will make a direct donation Please send me a tax deductible receipt Payment options: Direct Debit BSB 032513 ACC 251784 Credit card through GoFundraise https://www.gofundraise.com.au/beneficiary/IDFA Cheque to IDFA PO Box 969 Penrith NSw 2751 type_submit_reset_12 SubmitReset