Please note that under the Privacy Act we advise that the information provided in this application form will be entered into our computerised membership database and will be used only for Kapiti SeniorNet business. You may at any time ask for a copy of your information.

Our Individual Membership Subscription is $30 per year. If renewed before May 1 it is reduced to $25.

A Joint (Couples) Membership is only $50 (reduced to $45 if renewed by 1 May) so please encourage your spouse to join and support us as well.

To apply for membership of SeniorNet Kapiti, please enter your details below and press Submit

Application Form

Title (optional) and Name of applicant(required)

Address(required)

Town(required)

Postcode(required)

Contact Phone Number - Day/Evening(required)

Mobile Phone Number (Optional)

Email address (applicant)(required)

Do you have any skills you could share with SeniorNet?

Year of Birth (applicant): (required)

Name of your Contact person in an Emergency(required)

Phone Number of your Contact Person(required)

If you are applying for a Joint Membership, please provide the following information for your partner/spouse, otherwise please scroll to the bottom: . . . . . .Title (optional) and Name of spouse/partner for Joint Membership

Mobile Phone Number (spouse/partner)

Email address (spouse/partner)

Does your partner have any skills they could share with SeniorNet?

Year of Birth (spouse/partner):

Payment for Membership can be made by Cash or Internet Banking to ANZ Bank a/c 06-0501-0746900-00 (if using Internet Banking, please enter your name in the Payee's Reference field). Our account name is SeniorNet Kapiti. Please indicate below how you will pay...(required)

Cash Internet Banking

If after pressing SUBMIT (and waiting more than 1 minute), your information is still in the input fields above, please check for any highlighted missing information and enter it. All fields marked “(required)” must be completed otherwise your information will not be forwarded to us. Thank you.