BIAWW Annual Membership Form

Annual Membership

Brain Injury Association of Waterloo-Wellington
Membership term: 1 Year

Must be an active member to vote at our Annual General Meeting

Thank you for your Support - It is greatly appreciated!

Brain Injury Association of Waterloo-Wellington (BIAWW)

1-41 River Rd E, Kitchener, ON, N2B 2G3

Website: www.biaww.org

Email: info@biaww.com

Phone: 226-747-6246
Annual Membership Fee*

Professional / Business: $100**New - second Professional / Business: additional $50Family: $30Individual: $20Survivor: $5
Organization
Type of Business/Profession
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
City*
Postal Code*
Registered Charity #891146862RR0001
The BIAWW captures photos and/or videos of activities and events including but not limited to: art projects, program participation, and community/fundraising events for the purpose of advertising, news releases, social media, and sharing the success of various projects. Please indicate below if you are in agreement with us using photos or videos you are captured in.*

YesNo
Are you 55 years or older? This information is collected only to inform funders of the demographic we serve.

YesNo
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