Membership Form 2020 – 2021

MEMBERSHIP FORM

April 1st, 2020 to March 31, 2021

Annual Membership Fee of $10

MEMBER:

FOR NEW MEMBERS - How did you hear about us?

PARENT (MEMBER)

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

HOME PHONE NUMBER:

CELL PHONE NUMBER:

EMAIL ADDRESS:

COMPLETE ADDRESS:

SPOKEN LANGUAGE(S):

FAMILY TYPE:

EMPLOYMENT:

Mother:
Father:

EMPLOYER(S):


COUNTRY OF ORIGIN (other than Canada):

DATE OF ARRIVAL IN CANADA:

WHICH PROGRAMS WILL YOU USE THIS YEAR?

THIS YEAR I WANT TO BE INVOLVED IN:

Other (specify):

CHILD / YOUNG ADULT - 1:

Sex:

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

CHILD ATTENDING SCHOOL IN 2020-2021?

NAME OF INSTITUTION:

YOUR CHILD / YOUNG ADULT LIVES:

PRINCIPAL DIAGNOSTIC (check only one box):

CHILD / YOUNG ADULT - 2:

Sex:

LAST NAME:

FIRST NAME:

DATE OF BIRTH:

CHILD ATTENDING SCHOOL IN 2020-2021?

NAME OF INSTITUTION:

YOUR CHILD / YOUNG ADULT LIVES:

PRINCIPAL DIAGNOSTIC (check only one box):

IMPORTANT NOTICE

To enable Solidarité de Parents de Personnes Handicapées to pursue its mission and to comply with the "Law on the Protection of Personal Information in the Private Sector," we urge you to answer the following questions, sign this form and return it to Solidarité de Parents de Personnes Handicapées (address overleaf).

In addition, in order to avoid significant costs to the organization, e-mail will be the preferred means of communication.

Thank you for your cooperation

AUTHORIZATION REQUEST FOR TAKING PICTURES AT DIFFERENT EVENTS

I authorize the association to take pictures at various events (AGA, association’s activities) and to use them appropriately (website, Facebook, annual report, etc.).

WHEN YOU MAKE A DONATION, YOU ARE GIVING RESPITE SERVICES. THIS IS A PRECIOUS GIFT. PLEASE HELP FUND RESPITE SERVICES NOW.