Nouveau Adhésion membre anglais

INDIVIDUAL APPLICATION FORM TO BECOME A MEMBER OR RENEW YOUR MEMBERSHIP OF AUTISME MONTRÉAL
**Free membership for student who does not use the services of the organization: For the form, please contact us by email at accueil@autisme-montreal.com
Saisissez une question*

New applicationRenewal
MrMsOther
Name*

First nameLast name
Institution's name for professional member
Address*

Street

TownProvince

Postal Code
e-mail address*
exemple@exemple.com
I agree to receive all correspondence by email.*

YesNo
*A member who does not wish to receive our email communications may receive certain information (services, activities and registration dates) by mail three times a year, in January, March and September.
Phone*

Regional CodeNumber
Cellulaire

Regional CodeNumber
Child's name 1
Sex:

FM
Date of Birth

MoisJouran
Child's name 2
Sex:

FM
Date of Birth

MoisJouran
Child's name 3
Sex:

FM
Date of Birth

MoisJouran
Cotisation Membre*
prevnext( X )
Parent member: any member of the extended family$30.00CAD

User member: Anyone with autism spectrum disorder$30.00CAD

Support member: Any professional and any individual who wishes to support the actions of the corporation$55.00CAD
Language spoken*

FrenchEnglish
I have read and accept all of the policy statements. IMPORTANT, you must read the policy to accept the membership conditions.
Click here to view the policy
Signature*
Date*

MoisJouran
"Please note that Autisme Montréal will need your SIN (social insurance number), in order to be able to issue a Relevé 24 for your taxes at the end of the year, in the event that you use one of the following direct services: La Maisonnette Respite Service, Summer Respite Service, Swimming Lessons, Christmas and Spring Break Camps. "
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