CHARGE Syndrome Canada

PO Box 61509, Fennell Postal Outlet

Hamilton, ON, L8T 5A1

 Website: www.chargesyndrome.ca

Registered Charity # 888-365-707-RR 0001

MEMBERSHIP FORM

Annual membership is open to any person who supports the objectives of CHARGE Syndrome Canada.

*Print this form and send to the address above with a check or money order

1. Personal Information

Name

Street Address

City

Province /State

Postal Code / Country

Telephone Number

E-mail Address

2.  DATE: ________________________________________________________________________

  3.  CHARGE DATA:   

BIRTHDATE _________________    MALE ¨    FEMALE ¨

4. Please indicate membership type:	¨ New application	¨ Renewal
¨ Standard Membership (individual or family – one vote) CAD $20	¨ A Professional, Library, educational institution, OR organization (one vote) CAD $30	¨ CORPORATE LEADER Membership (non-voting) CAD $100