Renewal or Member Registration Active or Supporting Member

I would like to * Renew my membershipBecome a member

Which membership category best suits you?
Active MemberSupporting Member

Age range * 15 to 18 y/o18 to 35 y/o36 to 49 y/o50 to 65 y/o66 and overI prefer not to answer

What type of disability do you have? Multiple answers possible
VisualHearing impairMotorCognitiveMental health disorderNeurologicalIntellectual disabilityAutism spectrum disorderNoneI prefer not to answer

Do you have any special needs to ensure your full participation?Large prints documentsBraille documentsCaptioningHelp with feeding yourselfHelp to go to the bathroomOther (specify) :

Would you like to be added to our mailing list to receive the latest news from AFH?
YesNoI'm already registered

How would you like to pay? * By interac transfer, please write to projet@actionfh.ca to know the peocedure.By cheque sent by mailCash sent by mailAs an active member, I would like to benefit from the following membership program.

Would you like to pay for more than one membership in order to contribute to the program? * YesNo

Have you completed this form on behalf of a minor? * YesNo

If yes, please indicate your relationship with this person ParentGuardianCaregiver

By checking “I agree” you agree that the information you have provided throughout this form will be consulted by the AFH team and kept until you inform us of your wish to end your membership. These answers will be used for communication and statistical purposes only.

If you choose instead to click on “I decline” below, we will destroy your responses, but it is possible that someone else may have viewed them first.

If you have completed the form for a minor, the same warning applies. Please ensure that the minor consents.
I AGREEI DECLINE