Membership Application

 

Login Details

* Create a Login Name:
* Login Password:
* Retype Password:

 

Personal Information

* First Name:
Middle/Initial:
* Last Name:
* Gender:
* Birth Date: / /
* Home Address:
* City:
* Province/State:
Province (Foreign)
* Postal Code: -
Country:
* Email:
* Home Phone:
Fax:
Web Site:

Annual Membership Fees
* Membership: Individual with Low Income $5
Individual $20
Organization $50 (non-voting)
CMHA Staff $20 (non-voting)
Check this box to have your membership renew automatically on January 1st of each year.
I would also like to make a donation to support the work of CMHA, Vancouver-Fraser Branch: