89 Culver Street
Simcoe, Ontario
N3Y 2V5
Telephone: (519) 426 - 0007
Fax: (519) 426 - 9549

E-mail: admin@communitylivingaccess.ca
www.communitylivingaccess.ca
 
 MEMBERSHIP APPLICATION and RENEWAL FORM
Please Print
Name:____________________________________________________________________________________
Address:__________________________________________________________________________________
City: _________________________   Province: ______________________ Postal Code: ________________
Telephone: _________________________________ (home)   _______________________________ (business)
E-mail address		_______________________________________________________________________
Please check each that applies to you
	“	Parent		“	Relative/Guardian		“	Volunteer	“	Community Member
	“	Friend		“	Supported Individual		“	Employee	“	other Agency
													Representative
General Membership:
Open to any person who supports the purposes and objectives of the Organization and who pays annual membership dues, except persons employed by this Organization, any similar organization or acting as a representative of such organizations.

Friends of the Association
Open to any person who supports the purposes and objectives of the Organization and who pays an annual fee, and is employed by this Organization, any similar organization or acting as a representative of such organizations.

We shall issue your receipt and membership card once we have received your payment.
Annual Membership Fee of $5.00 is due each January 1st.

Please check off one:
	“	General Membership Fee			“	Friends of the Association

Please check the areas which would be of interest to you:
	“	Board of Directors				“	Committees

	“	Fundraising					“	Volunteer (support enhancement)

Preferred method of contact?					“ Telephone     “   Direct Mail       “   E-mail

Would you like to receive your written correspondence by e-mail?			“ Yes       “   No

Can we provide your contact information to Community Living Ontario		“ Yes       “   No

Would you like to volunteer for any of our fundraising events?			“ Yes       “   No

-----------------------------------------------------------------------------------------------------------------

If you have enjoyed the Eye on Access newsletter, please help us fund the future publications by making a donation.   
A Tax Receipt will be issued
$10.00 ________$15.00________ $20.00_________ $25.00 ___________ Other $_____________
Name:_____________________________________ Address:________________________________________
City:__________________________________ Province________________ Postal Code__________________

If you require any further information, please contact Community Living Access Support Services 519-426-0007
Thank you for considering a membership with our Organization