Charitable Reg#: 107565665 RR0001

 

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 ($10.00 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!

 

 
 

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