Membership Form

Membership Form:

To join the SBHANA or renew your membership please complete the following form that will automatically be submitted to the SBHANA. Membership Fee is $20.00 per year and are valid from February 1st to January 31 of the year you renew.
Spina Bifida and Hydrocephalus Association of Northern Alberta (SBHANA) provides members and their families with a wide range of resources that assist with managing spina bifida and/or hydrocephalus. As a member of the SBHANA you will have access to support from the SBHANA office, educational materials, the latest news from the medical community, and relevant opportunities and information. A member in good standing with the SBHANA will have access to the associations Support Fund ($1500/year), Christmas Party, NoLimits Adult Group, New Parent Gift Bag, events and the SBHANA Monthly E-News.

For more information about any of the services that SBHANA provides please contact the SBHANA office at info@sbhana.org or call 780-451-2921
Type of Membership*

IndividualFamily MemberCare GiverGrandparentOrganization
Full Name*

First NameLast Name
Childs Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*

Area CodePhone Number
E-mail*
Person with spina bifida and/or hydrocephalus*
Childs Name
Date of birth of person with spina bifida and/or hydrocephalus

MonthDayYear
Date
Gender of person with spina bifida and/or hydrocephalus

FemaleMaleOther
I would like to be contacted regarding volunteer opportunities at SBHANA*

YesNo
I would like to volunteer for one or any of the following positions:

Special EventsFundraisingCommitteesNew Member SupportAssist with Social Media/WebpageBoard of Directors
I would like to be kept up to date on the latest SBHANA news, updates, programs, and social events by consenting to receiving SBHANA E-communications.*

YesNo
Is there a program you would like to see SBHANA offer?
Memberships are $20.00 per calendar year*

1 Year Membership2 Year Membership3 Year Membership4 Year Membership
Please submit payment by cheque or ETF transfer to info@sbhana.org
Payment Form

Pay on Line using SquarePay by E-Transfer to info@sbhana.orgPay by ChequeOther
Signature

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Yearly Membership$20.00CAD

Total $0.00CAD

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