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, 2016 - Aug 31, 2017

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:
Gender:
Date of Birth:

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 MB (CPAM) to use my mailing address and phone number for the purpose of informing me about upcoming events & activities, to distribute the newsletter or to mail me information regarding Cerebral Palsy or the association. I understand that CPAM will never sell, rent or distribute my personal information. I may withdraw my consent at any time with written notice.