Membership Form

Brain Injury Association of Sault Ste. Marie and District
Membership Form

Brain Injury Association of Sault Ste. Marie and District
Membership Form

This form is for joining only the BIASSMD. If you wish to join both the BIASSMD and OBIA please click the button below to go back to the membership page.
Personal Information

All information you provide will not be shared with any other agency or business without your written agreement.
Registrant's Full Name
First Name Last Name
Spouse or Partner's Full Name
First Name Last Name

Address

Home Phone Number
- Area Code Phone Number
Cell Phone Number
- Area Code Phone Number
E-mail
Registrant: Did you survive an ABI?
Partner: Did you survive an ABI?
Registration Fee: Registrant
Registration Fee: Spouse Partner
I agree to the fee noted above and realize that this fee is not a charitable donation and is not claimable inaccordance with the Income Tax Act of Canada.

I hereby request membership in the BIASSMD.
Sigature
Participation in Association Activities:

Please provide an answer to each of the following quesitions. Would you consider:
Joining the Board of Directors

Yes No
Becoming a Mentor

Yes No
Assist with education/displays

Yes No
Take a course

Yes No

Would you be interested in working with any of the following:

PLEASE DO NOT SUBMIT - PRINT AND MAIL. Thank you and welcome to the Brain Injury Association of Sault Ste. Marie and District. Someone will be in touch shortly.
Please mail this application and a cheque for the specified amount to:

Attention: Chantal Scopacasa

P.O. Box 22045,

Sault Ste. Marie ON,

P6B 6H4
Should be Empty: