Resident Membership Application

Reservation number*
SECTION A: Applicant Details
Prefix*
First*
Middle
Last*
Date of Birth*
DD slash MM slash YYYY
Email*
Second Email
Telephone (Home)*
Include country and area codes
Telephone (Mobile)*
Include country and area codes
Address for Correspondence*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home, postal or business address for direct mail
Permanent Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Photograph for Identification Card*
Accepted file types: jpg, png, Max. file size: 2 MB.
Provide a passport-type photograph, preferably in .jpg format. The photograph is to be:
- high resolution
- in colour
- recent
- head and shoulders only
- with light background for better printing
- with a smile Please make sure you name your file as Photo.
SECTION B: Resident Membership
Membership of our prestigious 101 year old international collegium of graduates entitles you to reside in our Melbourne college and use our facilities. Membership is discounted for residents who are enrolled in a course of post-graduate study. The first membership fee includes a Joining Fee.

Resident Membership entitles you to free or reduced fee participation in the GU Collegiate events shown in Section Q.
Joining Fee
Price:
Resident Membership
Price:
SECTION C: Reservation (Booking) for Residency
Hidden
Arrival Date
Arrival Date

Day
Month
Year
Arrival Time*

: Hours

Minutes

Check-in from 2.00pm
Hidden
Departure Date
Departure Date

Day
Month
Year
Number of people*
Room Type*
Residency Fee per Week*
Comments
Advance Payment of Residency Fee
Price:
Minimum two weeks when booked term of residency > 2 weeks
Room Bond
Price:
Key Bond*
Price:
Refundable within 14 days of departure date (subject to terms).
Car Park*
Price:
$10 daily or from $190 monthly
Internet Access*
Price:
$30 per month for 20GB; $40 per month for 50GB
SECTION D: Purpose of Visit to Reside at the Graduate Union
Purpose*
- Study - enrolled for study
- Other Purpose - e.g., sabbatical, research, teaching, etc.
University*
Faculty*
Department/School*
Academic Contact name*
Academic Contact email*
Academic Contact phone*
If enrolled for study, attach documentary evidence of enrolment (or letter of offer) to this application.
Evidence of enrolment (or letter of offer)*
Accepted file types: pdf, pdf, Max. file size: 64 MB.
Please make sure you name your file as fullName_enrolment.pdf
Student Identification Number*
Course code and name*
Expected date of graduation
MM slash DD slash YYYY
Course dates
Year 1
Start Date*
DD slash MM slash YYYY
End Date*
DD slash MM slash YYYY
Year 2
Start Date
DD slash MM slash YYYY
End Date
DD slash MM slash YYYY
Year 3
Start Date
DD slash MM slash YYYY
End Date
DD slash MM slash YYYY
End-award*

(e.g., doctorate, professional doctorate, masters, diploma)
Purpose of visit*
Letter of offer/invite*
Accepted file types: pdf, pdf, Max. file size: 64 MB.
Please make sure you name your file as fullName_offer.pdf
Staff or Visitor Identification Number
SECTION E: Tertiary Education Qualifications
(for all new graduate Resident Members)
Full Name at Graduation*
First Degree*
Year Name of Degree Obtained University

Other Degrees or Qualifications

Year	Qualification Obtained	University

SECTION F: Referees
Referees may be contacted at any time prior to or during the term of residency. Please provide details for professional or academic referees (e.g., lecturer, professor, employer, etc.)

Do not provide details for family members or friends.
Referee 1
Name*
Prefix First Last
How long has this referee known you?*
What is your relationship to this referee?*

(e.g., I was a student or employee of this person)
Referee 2
Name
Prefix First Last
How long has this referee known you?
What is your relationship to this referee?

(e.g., I was a student or employee of this person)
SECTION G: Applicant Details
Birth
Country of Birth*
Town/City/Village of Birth*
Are you of Aboriginal or Torres Strait Islander heritage?*
- No
- Yes, Aboriginal
- Yes, Torres Strait Islander
- Yes, both Aboriginal and Torres Strait Islander
Passport
Do you have a passport?*
- Yes
- No
Passport Number*
Country of Issue*
Date of Issue*
DD slash MM slash YYYY
Expiry Date*
DD slash MM slash YYYY
Driver's Licence
Do you have a Driver's Licence in any country?*
- Yes
- No
Licence Number*
Country of Issue*
Date of Issue*
DD slash MM slash YYYY
Expiry Date*
DD slash MM slash YYYY
Residency Status
Please choose your residency status in Australia*
Country of Citizenship*
Visa Type and Number*

Language

Other than English, I use the following languages at competency levels (Low, Medium or High):

Language	Competency in Speaking	Competency in Understanding	Competency in Writing	Competency in Reading

Insurance
Medicare Number
(for citizens of Australia only)
Private Insurance Number Name of Company Phone Number Email Policy Expiry Date
Ambulance Subscription Number Name of Company Phone Number Email Policy Expiry Date
SECTION H: Emergency Contact Details
In the event of an emergency The Graduate Union will endeavour to contact the first person listed to inform them of the emergency. If this person is not available, The Graduate Union will endeavour to contact the second emergency contact person listed. Please provide as much contact detail information as possible to ensure that we are best positioned to reach those who love and care about you.
Contact 1
Name*
Prefix First Last
Email*
Online account

e.g., Facebook, Skype
What is your relationship to this contact?*

e.g., I am the daughter/son, friend or patient of this person
Telephone (Landline)*
Include country and area codes. For calls to overseas, provide best time to call.
Telephone (Mobile)*
Include country and area codes. For calls to overseas, provide best time to call.
Contact 2
Name
Prefix First Last
Email
Online account

e.g., Facebook, Skype
What is your relationship to this contact?

e.g., I am the daughter/son, friend or patient of this person
Telephone (Landline)
Telephone (Mobile)
Doctor in Melbourne
If you do not have a doctor in Melbourne you may like to register as a patient with a general practitioner or other health professional at: The University of Melbourne Student Health Services, 138-146 Cardigan Street, Carlton. Telephone: +61 3 8344 6904.

This is located within walking distance of The Graduate Union.
Doctor
Name
Prefix First Last
Telephone
Address for Doctor
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home, postal or business address for direct mail
SECTION I: Medical Information
It is recommended that you inform The Graduate Union of any condition that may affect your health, safety and comfort, or the health, safety and comfort of others during your residency. The Graduate Union recommends that you provide this information although its provision is not mandatory. It is collected to assist in providing appropriate residential facilities and services, and in the event of accident or emergency.

Information provided to The Graduate Union is subject to the Information Privacy Act 1988, Health Records Act 2001, Equal Opportunity Act 1995 and The Graduate Union's Privacy Policy.
Are you willing to provide details about your health?*
- Yes
- No
As far as I am aware, I do <u>not</u> have any of the following:
- Asthma
- Stroke
- Severe Anxiety
- Head Injury
- Systemic Infections
- Major Surgery
- Back Pain
- Fits, Seizure, Epilepsy
- Fainting or Dizziness
- Depression
- Schizophrenia
- Eczema or Skin Disorders
- Hearing Impairment
- Visual Impairment
- Type 1 Diabetes
- High Blood Pressure
- Borderline Personality Disorder
- Habit of Smoking Cigarettes
- Physical Impairment that affects Mobility
- Gambling Addiction
- Drug Addiction
- Type 2 Diabetes
- Heart Condition
- Psychosis
- Cancer
- Alcohol Addiction
- Neck Pain
- Other
(Tick one (at least) or more.)
Please provide details (e.g. of allergies)
If any of the options are ticked, please provide sufficient information to enable The Graduate Union to provide first aid care and to advise ambulance, paramedic and health care staff in the event of an emergency. This information is kept in your resident records and is treated as private and confidential. It is released only in the event of an emergency to the GU staff and emergency and health services personnel involved in administering care.

Additional documents can be attached to this section, such as care plans and the names and contact details of professionals in the care team; medication list, dosages and schedule; known emergency procedure - e.g., in the event of an epilepsy attack, an asthma attack, a psychotic episode, a severe episode of depression or anxiety, hypoglycaemia, etc.; and mobility requirements - e.g., for wheelchair use, bathroom aids, etc.
SECTION J: Dietary Requirements
The Graduate Union provides breakfast seven days a week and dinner five nights a week (Monday to Friday) from our college kitchen and canteen. Our college has our own chef and kitchen staff members who come to know and care about our Resident and Non-Resident Members. We provide, on average 300 meals per day; and on some days, up to 500. Within these considerations, we endeavour to meet the most common dietary requirements.
Note: all meat is Halal.
Required Diet
(medical certificate required)
Please indicate the food that you cannot eat for health reasons (e.g., due to food allergy)
Dietary Preference
Please indicate the foods that you choose not to eat
SECTION K: Communications
The Graduate Union is proud to provide to members a monthly newsletter and the Melbourne Graduate periodical. These are made available to our international membership of graduates around the world.
Please indicate if you would like to receive these publications via Email.*
- Yes
- No
SECTION L: How did you learn about our association and college?
I was introduced by Member:
Name
Tick as many as apply
- Website search for graduate accommodation
- Website search for meeting services
- Website search for graduate membership association
- Word of mouth
- I discovered this Carlton gem when a member invited me to join them for a member function.
- I discovered this gem when I attended a meeting, seminar or conference here.
- Facebook
- Google Plus
- LinkedIn
- YouTube
- Pinterest
- Email
- Mural.ly
- Twitter
SECTION M: Covid-19
Declaration by Resident of Graduate House Self-Quarantine (Self-isolation)
Dear Resident,

A State of Emergency was declared in Victoria on the 16^th March 2020 to combat COVID-19.

You must self-quarantine (self-isolate) for a period of at least 14 days if you have:
• arrived in Australia after midnight on 15 March 2020;
• been diagnosed with COVID-19; and/or
• been in contact with someone who has been diagnosed with COVID-19.

Self-quarantine (self-isolation) means that you must stay in your room at Graduate House (including Barkly Place and Barry Street). It means that you must NOT:
i. leave your room;
ii. invite anyone into your room; and
iii. use shared Graduate House facilities, such as the kitchen, dining room, library or games room.

You may need medical care while in isolation – please email admingh@graduatehouse.com.au or telephone 9347 3428 to discuss this need. We will then work with you to leave your room under STRICT supervision or assist you in giving access to a health professional to come to your room.

In an emergency, you may be required to evacuate. We ask that you try to keep at least 1.5m away from all other residents when evacuating and when gathering in the designated evacuation space.

We require your completion, signing and return of a DECLARATION.

Your privacy is important to us. In providing the information in this form, you consent to our collection, use, processing, transfer, and/or disclosure of your personal data, including any sensitive data, in accordance with all applicable laws for the purposes of:
• monitoring, evaluating, and responding to the COVID-19 outbreak;
• providing accommodation and services in Graduate House having regard to Public Health Agency guidelines, and, to the extent necessary, for the safety of our residents and staff; and
• providing information to Public Health Agencies, medical personnel and any other relevant governmental agency.

If you decide not to complete this declaration form, we reserve all rights to exclude you from residency at Graduate House and/or evict you from Graduate House.

Thank you for your understanding and cooperation.
Question 1: Are you required to self-quarantine because you arrived in Australia after midnight on 15 March 2020 or because of your travel history?*
- Yes
- No
Question 2: Have you had close contact with someone who is diagnosed with or suspected of having COVID-19 in the past 14 days?*
- Yes
- No
Question 3: Do you have any reason to believe that you have or may have COVID-19?*
- Yes
- No
Question 4: Have you been in self-isolation previously?*
- Yes
- No
Country of self-isolation:*
Start date of isolation:

Day
Month
Year
End date of isolation:

Day
Month
Year
Hidden
Self-isolation
You have answered Yes in the question mentioned above and you MUST self-quarantine (self-isolate) for 14 days.
The degree to which we can support self-isolation varies across our accommodation wings:
Terrace wing (222-234 Leicester Street) – we are not able to support self-isolation in this wing at all as there are no bathrooms in these accommodation rooms.
Central wing and southern (Stella Langford) wing (210-220 Leicester Street) – we are able to support self-isolation through the provision of breakfast every day and dinner Monday to Friday delivered to your room.
Barry Street and Barkly Place – we are not able to support self-isolation at this time in this wing as we are not able to deliver meals safely. Self-isolation means that you are not able to leave your room – it is thus not possible for you to collect deliveries from the downstairs foyer.

You may also be required to self-isolate if you are already a resident, if you:
• become ill with COVID-19 related symptoms;
• are tested for or diagnosed with COVID-19;
• become aware of the need to self-quarantine while staying at Graduate House; or
• become aware of the need to self-quarantine within 14 days of your stay,

please inform us immediately by email admingh@graduatehouse.com.au or by telephone on 9347 3428 if any of the above occurs..

Please also follow the advice of https://www.dhhs.vic.gov.au/coronavirus.
*
Prefix First Last
Room No:*
Arrival date in Australia:*

Day
Month
Year
I agree that:*
- All information that I have provided is complete and correct.
- I am aware that missing or incomplete information, whether deliberate or the result of negligence, may exclude me from residency at Graduate House and/or result in eviction from Graduate House.
- I will abide by self-quarantine (self-isolation) requirements for 14 days and will not have any guests in my room during this required isolation period.
- I will inform Graduate House reception within ONE HOUR if I become ill with COVID-19 related symptoms
- I will inform Graduate House reception within ONE HOUR if I or a medical professional request(s) that I undertake a COVID-19 test
- I will inform Graduate House reception within ONE HOUR if I am tested for or diagnosed with COVID-19
- I will inform Graduate House reception within ONE HOUR if if I become aware of the need to self-quarantine while staying at Graduate House
- I will inform Graduate House reception within ONE HOUR if I become aware of the need to self-quarantine within 14 days of my stay.
- I understand that I may need to change rooms should there be a requirement for me to self-isolate and that this will be subject to availability
- I am aware that I may be fined up to $20,000 if I do not undertake required self-quarantine for 14 days OR if I invite/have someone in my room during a required isolation period.
Signature*
Date of signature*
DD dash MM dash YYYY
Payment
Payment Amount TOTAL
$ 0.00
Payment*
- Paying my own deposit (via Credit Card or Bank Transfer or Direct Debit)
- Department is paying my account
Payment Method*
- Debit/Credit Card
- Bank Transfer
- Direct Debit
Financial Institution*
Account Name:*
BSB:*
Account Number:*
Swift Code:
Start Date:*

Day
Month
Year
I would like to give regularly through my selected payment option*
I agree to the Automatic Payment Service Agreement
Automatic Payment Service Agreement
Signature*
We acknowledge our Donors
- I would like my donation to be anonymous and do not wish to have my name printed in any published lists.
We will send you a tax invoice (your donation is tax deductible) and include your name in donor lists. Check below if you do not wish to be so acknowledged.
Account Name: The Graduate Union of the University of Melbourne Incorporated
Bank: National Australia Bank
BSB: 083 170
Account Number: 51561 2137
Swift Code: NATAAU3303M
Name the transfer as your Surname and the word Resident Form. Please note that your application cannot be processed without receiving payment.
Contact Name*
Department*
Department Email*
Debit/Credit Card payments are provided by ‘Stripe’, a third party payment gateway. We do not store your credit card details, or have access to them.
Credit Card*
Card Details
Cardholder Name
The Graduate Union will confirm your Reservation within 14 days of receipt of payment.
Our FREE gift to you upon becoming a new member of The Graduate Union is a polo or t-shirt.
Indicate your preference for a polo (female or male) or t-shirt, and the size of garment required. Tick one option/size.
Free gift

Men's Polo XL XXL XXXL XXXXL

Men's T-shirt S M L XL XXL XXXL XXXXL

Women's Polo 8 10 12 14 16

Women's T-shirt 12 14 16 18
2022 Residential Agreement Terms and Conditions
*
- I certify that the information provided by me, the applicant for residency, is correct, accurate and sufficient to enable The Graduate Union to serve reasonably my comfort and safety, and the comfort and safety of others during my residency.
*
- I authorise The Graduate Union to consent to my receiving emergency medical or surgical treatment as may be deemed necessary, in the event that I am unable to communicate or The Graduate Union is unable to contact an immediate family member/emergency contact.
*
- I authorise The Graduate Union to contact the emergency contacts listed in this form in the event of an emergency and as may be deemed necessary.
*
- I confirm that I will notify The Graduate Union when any of the information changes, that I have provided in this Application Form before and during my term of residency.
*
- I have read and agree to the Residential Agreement Terms and Conditions.
*
- I have attached my letter of offer or other appropriate documentation from the university.
*
- I have attached a digital photo of myself.
*
- I hereby authorise The Graduate Union of The University of Melbourne Incorporated to settle any outstanding debts and penalty fees that I have not settled with cancellation of a confirmed reservation, with early departure from residency and/or prior to departure on my Reserved End Date.
*
- I certify that I will not dispute settlement of outstanding debts and penalty fees that correspond to this Resident Membership Application Form and Residential Agreement Terms and Conditions with The Graduate Union of The University of Melbourne Incorporated.
*
- I have read and understood the Privacy Policy shown at www.graduatehouse.com.au/membership/privacy-policy.
*
- I commit to learn to state the 17 UN agreed 2030 Sustainable Development Goals www.undp.org/content/undp/en/home/librarypage/corporate/sustainable-development-goals-booklet.html
*
- I hereby authorise The Graduate Union to use, reproduce, and publish photographs or videos that may pertain to me, including my image, likeness, or voice without compensation. I understand that this material may be used in various print and digital publications (The Graduate Union newsletter, Melbourne Graduate, Graduate House website and blog, and social media channels, and other marketing material relating to the Graduate Union and Graduate House). I understand that these materials may appear online or in print. This authorisation is continuous and may only be withdrawn by my specific rescission of this authorisation.
*
- I agree to provide a signed copy of the Authorisation sheet within 48 hours of beginning my stay at The Graduate Union.
Details for Bank Transfer Account Name: The Graduate Union of the University of Melbourne Incorporated
Bank: National Australia Bank
BSB: 083 170
Account Number: 51561 2137
Swift Code: NATAAU3303M
Name the transfer as your Surname and the word Resident Form. Please note that your application cannot be processed without receiving payment.
The Graduate Union will confirm your Reservation within 14 days of receipt of payment.
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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Resident Membership Application

SECTION A: Applicant Details

SECTION B: Resident Membership

SECTION C: Reservation (Booking) for Residency

SECTION D: Purpose of Visit to Reside at the Graduate Union

SECTION E: Tertiary Education Qualifications

SECTION F: Referees

SECTION G: Applicant Details

SECTION H: Emergency Contact Details

SECTION I: Medical Information

SECTION J: Dietary Requirements

SECTION K: Communications

SECTION L: How did you learn about our association and college?

SECTION M: Covid-19

Payment

2022 Residential Agreement Terms and Conditions

About the person completing this form

About the donation

About the donor

Payment of the donation

Please direct cheque to The Graduate Union of The University of Melbourne Inc.

Amount

Your Details

Payment

Men's Polo	XL	XXL	XXXL	XXXXL
Men's T-shirt	S	M	L	XL	XXL	XXXL	XXXXL
Women's Polo	8	10	12	14	16
Women's T-shirt	12	14	16	18