Membership

Annual Membership Application

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AUTISM CALGARY ASSOCIATION
174, 3359 – 27th Street NE Calgary, Alberta T1Y 5E4

ANNUAL MEMBERSHIP APPLICATION
New or Renewal    (Please circle one)

NAME:

________________________________

ADDRESS:

________________________________

PHONE:

________________________________

E-MAIL:

________________________________

CATEGORY:

_   Parent

_   Interested Professional, Educator or Caregiver

Other _____________________

MEMBERSHIP FEE: (we accept VISA, MasterCard, cheques or cash)

$ 25.00

DONATION (taxable receipt will be issued):

$______________

TOTAL:

$______________