The Cerebral Palsy Association of Manitoba

Member Application

Submit Application		Payment Options		Thank You
Submit Application

Please complete the following information to renew or submit a new application for membership. After submitting your application, you will be given the option to make your payment online.

Type of Membership:

Family/Individual - $10.00
Business/School/Association - $25.00

Application Type:

New Membership
Renewal

Membership Period:

Sep 1, 2021 - Aug 31, 2022

Contact Information:

Name:
Address:
City/Town:
Province:
Postal Code:
Email Address:
Home Phone:
Work Phone:
Cell Phone:

Family Member with Cerebral Palsy (if applicable):

Name:
Date of Birth (optional):

Make a Donation, in Addition to your Membership:

All money raised is truly appreciated and stays in Manitoba to support individuals and families affected by Cerebral Palsy.

Donation Amount: $

Use Contact Information Entered Above on Tax Receipt

Name:
Address:
City/Town:
Province:
Postal Code:

Consent:

By clicking "Submit Application" below, I consent for The Cerebral Palsy Association of Manitoba (CPMB) to use my mailing address and phone number for the purpose of informing me about upcoming events and activities, to distribute the newsletter or to mail me information regarding Cerebral Palsy or the Association. I understand that CPMB will never sell, rent or distribute my personal information. I may withdraw my consent at any time with written notice.