Information Line: 519-453-3198
MEMBER APPLICATION FORM
Please complete the form as best you can, and tick √ all that apply to you.
First NameLast NameI am applying as aType of Membership I would like(for Affiliate/Organization Members) Organization NameOrganization Contact NamePosition in OrganizationMailing/Street AddressApt No.CityProvince/TerritoryPostal CodeE-mail
LandlineCellI would like to receive all written communications by
I am on
Have you been formally diagnosed with FM?If yes, what year?
What, if any, other chronic illnesses do you have?
Multiple Chemical Sensitivity/Environmental Sensitivities
Irritable Bowel Syndrome
Gastroesophageal Reflux Disease (GERD)
Other type(s) of chronic illness not listed above
I do not have a chronic illness
I am currently
on disability benefits
My professional qualificationsMy skillsI am interested in volunteering with this organization
If YES, which Committees/work are you interested in?
Awareness Standing Committee
Research Standing Committee
Education Standing Committee
Advocacy Standing Committee
Payment of $