Form
CONTACT ADDRESS
7401 Newman, Suite 6, LaSalle Québec H8N 1X3Tel.: (514) 935-4951 Email: cbacmtl@gmail.com
MEMBERSHIP FEE
General Membership fee is $25.00. General Membership fee is due annually before April 1st. Lifetime Membership and Honorary Membership pay no annual fee.
Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Birth
*
Medical Card Number
*
Telephone Number
*
Cellular Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMERGENCY CONTACT:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship
*
Emergency Contact Phone Numbers
*
VOLUNTEER SERVICES: Are you interested in being a volunteer with CBAC
VOLUNTEER SERVICES: In what capacity would you like to volunteer?
On what Committee would you be interested in volunteering:
What services would you like to perform?
MEMBERSHIP TYPE
General Membership is open to any resident of the province of Quebec, aged fifty-five (55) and over. Lifetime Membership is bestowed when a member attains eighty (80) years of age. Honorary Membership is conferred or bestowed to persons per By-Laws.
MEMBERSHIP TYPE
PHOTO PERMISSION In becoming a Member of The Council for Black Aging Community of Montreal, also referredto as CBAC, you consent to your likeness and photographs being used in CBAC’s print, online and video-based marketing materials and other organization publications. I hereby authorize The Council for Black Aging Community of Montreal, also referred to as CBAC, to publish photographs taken of me, my name and likeness, for use in CBAC’s print, online and video-based marketing materials and other organization publications. I hereby release CBAC from any reasonable expectation of privacy or confidentiality associated with the images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with publication of these photographs. I hereby release CBAC, its contractors, its employees, and representatives involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation. I have read and understand the above: Name (print):___________________________________________ Signature: ______________________________________________ Date: __________________________________________________
*
PHOTO EXEMPTION While I acknowledge that membership in CBACcomes with automatic photo permission, I would like to be exempted from same. Name: ___________________________________ Signature: ________________________________ Date: ____________________________________
*
PAYMENT OPTIONS
Signature
*
Submit
Submit
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Should be Empty: