AFFILATE APPLICATION FORM for THE CAN'T WAIT PROGRAM

Thank you for agreeing to participate and recognise the importance of the Can't Wait card allowing people with IBD access to your toilets in cases of need.

PRIVACY

The information collected will be recorded and stored in the Can't Wait Card database, and used for the purposes of administering the Can't Wait Card program in accordance with the privacy principles in the Information Privacy Act 2000 (Vic).

ORGANISATION DETAILS

* Denotes a mandatory field
 Organisation Name: * 
 Address: * 
 Suburb: * 
 State: * 
 Postcode: 
 Postal Address: 
 Postal Suburb: 
 Postal State: 
 Postal Postcode: 
 Telephone: * 
 Fax: 
 Website: 
Must be full URL e.g. http://www.mysite.com.au
 Logo: 

CONTACT PERSON FOR AFFILIATION RELATED ISSUES

 Title: 
 First Name: * 
 Surname: * 
 Position: * 
 Telephone: * 
 Fax: 
 Email: 

A BRIEF DESCRIPTION ABOUT YOUR ORGANISATION

LOCATIONS

List below the locations your organisation will accept the Can't Wait Card:


   Same as Above 


   Business Name: 

   Street Address: 
   Suburb: 
   State: 
   Contact Number: 

   Business Name: 

   Street Address: 
   Suburb: 
   State: 
   Contact Number: 

   Business Name: 

   Street Address: 
   Suburb: 
   State: 
   Contact Number: 
 
   More sites:  (We will be in touch with you for details)

DISPLAY MATERIALS AND INFORMATION PACKS

You will be provided with an information pack that will include a 'How To' guide. The 'How To' guide will outline

  • where best to display the Can't Wait sticker
  • provide you with information pamphlets and promotional material
  • how to re-order literature

STICKER SIZE

There are two sizes of stickers available for your use, please indicate your preferred size.

Small: 7cm height 11.5cm width
Regular: 14.5cm height 21cm width

Preferred Sticker Size:

ORGANISATION SIZE

The number of display stickers and quantity of literature provided to you will vary with the size of your organisation. Please indicate below what best describes your organisation.

  • Small (suitable for single locations)
  • Medium (suitable for up to 10 locations)
  • Large (suitable for up to 30 locations)

Your organisation is best described as:

DONATION BOXES & MERCHANDISE

You may also wish to support CCA further by including a donation box or merchandise to be sold at your establishment.

Yes Please    I would like to order a donation box. Number of boxes
I would like merchandise to be sold at my business.
Please include pack(s)
Packs include      10  pins
10  pens
10  wrist bands
10  reusable bags
 
No thank you    I do not wish to include a donation box or sell merchandise.

AFFLIATE AGREEMENT

(Must be completed)

I am an authorised representative of the above mentioned organisation.

On behalf of the organisation:

 1  I understand and accept the Can't Wait Card program Terms and Conditions and agree to accept the Can't Wait Card at the above mentioned venue(s).
 
 2  I consent to the organisation's name, service description, list of services and website address being published on the Crohn's and Colitis Australia web site or in other promotional communications as a Can't Wait Card program affiliate.
 Yes  No
 
 3  The organisation intends to collect statistics on the use of the Can't Wait Card at its venues/events, and will be prepared to share this non-identifying data with Crohn's and Colitis Australia for evaluation purposes.
 Yes  No
 
 4  The organisation will begin to officially recognise the Can't Wait Card from:
Date  Must be in format: dd/mm/yyyy
 
 Name of authorised representative: 
 Position: 
 Authorising Date:  Must be in format: dd/mm/yyyy