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9
Membership Registration
Membership Registration
For the Membership Year Ending March 31, 2023
Name
(Required)
First
Last
Address
(Required)
Street Address (Box # and/or Civic #/County Road/Street Address if in the rural area.)
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
Email
As a feature of our Membership you automatically become a member of Community Living Ontario Membership Listing. Do you approve of Community Living – Stormont County giving your name, address and telephone number to C.L.O?
(Required)
Yes
No
Family Membership
(Required)
For FAMILY MEMBERSHIP please list those residing at above household: (all residents 18-years-of-age and older will be issued a Membership card). All Members Receive C.L.S.C. Mailings
I wish to register additional people.
This is a single registration
1
First
Last
2
First
Last
3
First
Last
4
First
Last
Membership Categories
People Supported by Community Living
Price:
Free!
Individual
Price:
$ 5.00 CAD
Quantity:
Family
Price:
$ 10.00 CAD
Quantity:
Corporate
Price:
$ 50.00 CAD
Quantity:
Donation
(Required)
I WISH TO MAKE A DONATION (A tax receipt will be mailed in the amount of the donation).
Yes
No
Amount
If desired.
Total
Credit Card
Please check if you have activated a Stripe feed for your form.
THANK YOU FOR YOUR SUPPORT
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