APPLICATION FOR MEMBERSHIP

	Home · Who We Are · CONTACT US · CAREERS · Ways To Support · SPECIAL EVENTS

Kerry's Place Autism Services & Kerry's Place Residential Services Membership Application and Donation Form

Name:
Address:

City:		Province:
Postal Code:
Phone (home):
Phone (bus):

Fee Structure (please check the appropriate box)

Individual Membership $20.00

Persons with Autism, Seniors and Students               $15.00

Corporate Membership $60.00

Associate Membership for Staff/Management (non-voting) $20.00

I would like to make a donation of:                                 $_____________

                    Receipt required ($20.00 or more)
                    No receipt required

      Total amount (Membership fee + Donation)                    $_____________

Method Of Payment

Cheque - Payable to Kerry's Place Autism Services Money Order
MC or Visa # ________________ Exp. Date ______ Signature _____________

Please make cheque or money order payable to:
Kerry's Place Autism Services
34 Berczy Street, Suite 190
Aurora, Ontario L4G 1W9

Please print this form and forward with your chosen method of payment to the above address.

Please note:

Only Corporate memberships are eligible for charitable receipts for membership fees.

Membership in Kerry's Place Autism Services also grants dual membership in Kerry's Place Residential Services (KPRS) and voting privileges at both Annual General Meetings.

Members will receive a copy of "Living With Autism", our quarterly newsletter.

If you are already a member, thank you for your support!

HOME

The information provided is presented by Kerry's Place Autism Services for
informational purposes only and for careful review by the parent or caregiver. Kerry's Place Autism Services does not endorse any treatments or services; any action taken should be first reviewed with your specific Health Care team.

The Community Crisis Response Network supports persons in crisis whose needs require immediate response from a range of service providers. Connected by formal working partnerships, the Network responds to an immediate crisis and ensures the appropriate linkages for a longer-term solution. The Network assists persons with a developmental disability, an acquired brain injury, a serious mental illness, or a dual diagnosis. Callers can access these services by calling 310-COPE(2673)

Hit Counter

Charitable Registration #: 107565665 RR0001